How to Appeal a Health Insurance Company or Marketplace Decision

ObamaCare and Appeals – Everything You Need to Know About Expanded Appeal Rights Under the Affordable Care Act

The Affordable Care Act (ObamaCare) expanded health insurance appeal rights. Under the ACA it easy to appeal any health insurer or marketplace decision.^[1]

Specifically, you have the right to an internal and external appeal of any decision made by your insurer or the marketplace.

Here are the most important things to know about the process:

1. The ACA expanded appeal rights, under the law you have the right to appeal almost any marketplace or insurance company decision.
2. There is a wide array of decisions you can appeal, it can be a denial of a claim, being dropped for non-payment, or cost assistance being rejected.
3. Who you appeal to depends on who issued the denial, if it is related to cost assistance and eligibility, it is probably a marketplace appeal, if it is related to payment or medical claims, it is typically your insurer.
4. You generally have a short window of time in which to start the appeal process. The length of time you have depends on what type of decision you are appealing, but it can be as little as 15 days.
5. A good first step is typically to call your insurer or the marketplace and/or let them know you want to appeal a decision. This will almost always be followed by completing a written request or filling out forms. When in doubt, put it in writing.

That is the basics. If you don’t agree with a decision, start the appeal process ASAP! With that said, there are more details to cover.

Below we cover your appeal rights and how to appeal a health insurance company denial or Marketplace decision. This includes how to appeal a health insurance company decision in regard to cost-sharing or coverage through internal and external appeals, how to get help appealing a Marketplace decision in regard to costs and coverage, and even how to appeal decisions from the SHOP marketplace for small business.

Keep reading to learn more about how to file a complaint, a few tips and tricks, and how the Affordable Care Act improves your rights in regard to the appeal process.

IMPORTANT: In general the most important thing to know about appeals is you have appeal rights, but you also have a window of opportunity in which to act. Always get the appeal process started ASAP, once the process is started things become much more flexible. Especially when it comes to missed payments, the window of opportunity to start the appeals process may be limited.

Appealing a Marketplace Decision

If you don’t think the Marketplace made the right decision in regard to eligibility, income, exemptions, or another factor you can file an appeal.

What Decisions Can be Appealed?

You can appeal the following kinds of Marketplace decisions:

• Whether you’re eligible to buy a Marketplace plan
• Whether you can enroll in a Marketplace plan outside the regular open enrollment period
• Whether you’re eligible for lower costs based on your income
• The amount of savings you’re eligible for
• Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
• Whether you are eligible for an exemption from the individual responsibility requirement

How to Appeal a Health Insurance Marketplace Decision

When you fill out an application with HealthCare.gov or your state’s Marketplace you’ll get a notice that explains what you qualify for and will include appeal instructions and the timeframe you have to appeal the decision. You can either file an appeal by yourself or get assistance filing an appeal from the Marketplace.

Make sure to hang on to your eligibility notice and keep in mind appeals can affect the coverage of everyone on the plan. In some states appealing a Medicaid or CHIP appeal requires contacting your state Medicaid office (as explained in your eligibility notice).

In general, you can appeal by:

• Writing a letter to:
  Health Insurance Marketplace
  Attn: Appeals
  465 Industrial Blvd.
  London, KY 40750-0061
• Mailing in an appeal request form, using the proper form.
• Faxing your appeal request to a secure fax line: 1-877-369-0130

After your appeal, you will receive a letter notifying you that your appeal was received and will explain what to do next. You may get a letter asking for more information. Typically appeals can take up to 90 days.

If you have questions, contact the Marketplace Call Center at 1-800-318-2596 / TTY: 1-855-889-4325.

How to Request an Expedited Appeal

If an appeal would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function you can request an expedited appeal. If the expedited appeal is accepted the Marketplace will rush a final decision as quickly as your specific situation requires.

Please see HealthCare.Gov for more information on appealing a HealthCare.Gov or state Marketplace decision.

Appeal a SHOP Marketplace Decision

Both employers and employees have rights in regard to appealing a decision made by the SHOP marketplace. Denial of eligibility and the SHOP not responding in a timely manner can both be appealed.

You can appeal by filling out one of the forms below.

• SHOP appeals form for employers (PDF)
• SHOP appeals form for employees (PDF)

Mail your completed appeals form to:

Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0001

An authorized representative can file an appeal for you. You may also get help in a language other than English.

Learn about appealing a decision in the SHOP Marketplace for small businesses.

Call the SHOP Small Employer Call Center at 1-800-706-7893 (TTY: 711). Monday through Friday, 9 a.m. to 7 p.m. ET. Agents and brokers helping small businesses can use this phone number too.

Appealing a Health Insurance Company Decision

Above we covered how to appeal an ObamaCare Marketplace decision below we cover how to appeal a decision by an insurer.

Your Health Insurance Appeal Rights

Before beginning the process of appealing to an insurance company, make sure you understand your following rights. You have:

(1) A right to information about why a claim or coverage has been denied;

(2) A right to see and respond to all information used in the internal appeal decision; and

(3) A right to an independent review (also called an external appeal).

ObamaCare Rapid Appeals

Under the ACA consumers can appeal insurance company decisions to an independent reviewer and receive a response in 72 hours for urgent medical situations (unlike the standard appeal process which can take much longer).

In most cases, you’ll first make an appeal to your health insurance provider and then rely only on an external appeal if your claim is denied. However, in emergency situations, you should exercise your right to a rapid external appeal immediately.

Please see the external review process below to quickly understand how the appeal process works for urgent medical situations.

The Right to Appeal

There are two different ways to appeal a decision by a health insurance company, an internal appeal, and an external appeal. In most cases, the proper course of action is to simply call your insurer and have an internal appeal done. If your claim is still denied then you move on to an external appeal of your claim. However, in emergency situations, you should take advantage of your right to a rapid appeal within 72 hours to ensure that you don’t go untreated due to a denied claim.

The information below is compiled from HealthCare.gov and is meant to allow users to find all important appeal information in one place. HealthCare.gov is the official website for the Affordable Care Act. When in doubt call the Marketplace helpline for further guidance: 1-800-318-2596 / TTY: 1-855-889-4325

• Internal appeal: If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.

• External review: You have the right to take your appeal to an independent third party for review. This is called an external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.

Internal Appeal: Appealing a Denied Claim Through Your Insurer

There are 3 steps in the internal appeals process:

1. You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.

2. Your health plan denies the claim: Your insurer must notify you in writing and explain why:

   • Within 15 days if you’re seeking prior authorization for a treatment
   • Within 30 days for medical services already received
   • Within 72 hours for urgent care cases

3. You file an internal appeal: To file an internal appeal, you need to:

   • Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.

   • Submit any additional information that you want the insurer to consider, such as a letter from the doctor.

   • The Consumer Assistance Program in your state can file an appeal for you.

You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.

If your insurance company still denies your claim, you can file for an external review.

What papers do I need?

Keep copies of all information related to your claim and the denial. This includes information your insurance company provides to you and the information you provide to your insurance company like:

• The Explanation of Benefits forms or letters showing what payment or services were denied
• A copy of the request for an internal appeal that you sent to your insurance company
• Any documents with additional information you sent to the insurance company (like a letter or other information from your doctor)
• A copy of any letter or form you’re required to sign, if you choose to have your doctor or anyone else file an appeal for you.
• Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.
• Keep your original documents and submit copies to your insurance company. You’ll need to send your insurance company the original request for an internal appeal and your request to have a third party (like your doctor) file your internal appeal for you. Make sure to you keep your own copies of these documents.

What kinds of denials can be appealed?

You can file an internal appeal if your health plan won’t provide or pay some or all of the cost for health care services you believe should be covered. The plan might issue a denial because:

• The benefit isn’t offered under your health plan
• Your medical problem began before you joined the plan
• You received health services from a health provider or facility that isn’t in your plan’s approved network
• The requested service or treatment is “not medically necessary”
• The requested service or treatment is an “experimental” or “investigative” treatment
• You’re no longer enrolled or eligible to be enrolled in the health plan
• It is revoking or canceling your coverage going back to the date you enrolled because the insurance company claims that you gave false or incomplete information when you applied for coverage

How long does an internal appeal take?

• Your internal appeal must be completed within 30 days if your appeal is for a service you haven’t received yet.
• Your internal appeals must be completed within 60 days if your appeal is for a service you’ve already received.
• At the end of the internal appeals process, your insurance company must provide you with a written decision. If your insurance company still denies you the service or payment for a service, you can ask for an external review. The insurance company’s final determination must tell you how to ask for an external review.

What if my care is urgent and I need a faster decision?

In urgent situations, you can request an external review even if you haven’t completed all of the health plan’s internal appeals processes. You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function. You may file an internal appeal and an external review request at the same time.

A final decision about your appeal must come as quickly as your medical condition requires, and at least within 4 business days after your request is received. This final decision can be delivered verbally, but must be followed by a written notice within 48 hours.

External Appeal: Appealing a Denied Claim Externally

There are 2 steps in the external review process:

1. You file an external review: You must file a written request for an external review within 60 days of the date your insurer sent you a final decision. Some plans may allow you more than 60 days to file your request. The notice sent to you by your health insurance issuer or health plan should tell you the time frame in which you must make your request.

2. External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.

Types of denials that can go to external review

• Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan

• Any denial that involves a determination that a treatment is experimental or investigational

• Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage

What are my rights in an external review?

Insurance companies in all states must participate in an external review process that meets the consumer protection standards of the health care law.

State: Your state may have an external review process that meets or goes beyond these standards. If so, insurance companies in your state will follow your state’s external review processes. You’ll get all the protections outlined in that process.

Federal: If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.

Depending on your plan and where you live, the following may apply to you:

• Insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations in states where the federal government oversees the process.
• If you’re in an employer-sponsored health plan, you may not be eligible to participate in a state-run external review process.
• If your plan doesn’t participate in a state or HHS-administered external review process, your health plan must contract with an independent review organization.

How do I learn more about my state’s external review?

• Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It’ll give you the contact information for the organization that will handle your external review.
• See this state list maintained by the HHS’s Center for Consumer Information & Insurance Oversight.

How long does external review take?

Standard external reviews are decided as soon as possible – no later than 60 days after the request was received.

If my health insurance company participates in the HHS-administered external review process, how do I request an external appeal?

• Call toll free: 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.
• Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
• Submit a request via email: is [email protected]
• Visit www.externalappeal.com. In the future, you’ll be able to file a request using a secure website.

Can someone file an external review for me?

You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf. An authorized representative form is available at: www.externalappeal.com

How much does an external review cost?

If your health insurance company is using the HHS-administered external review process, there’s no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can’t be more than $25 per external review.

Where can I get help filing an appeal?

If you need help filing an internal appeal or external review, your state’s Consumer Assistance Program (CAP) or Department of Insurance may be able to help you.

Contact HealthCare.gov for more information.

More Facts on the ACA: Rapid Appeals and Other Protections

Understanding the information above is important if you are facing a denial of your insurance claim or a treatment. Of course, there is a lot more to the law beyond your right to appeal, check out the other benefits of the Affordable Care Act to learn more about your benefits, rights, and protections under the law.

How To: Health Insurance Appeals

1. Appealing an insurance company decision. HealthCare.Gov.