THE APPEALS PROCESS
What Happens When Your Health Insurance Company Says "No"
Adapted from a publication of the Colorado Department of Regulatory Agencies - Colorado Division of Insurance
Question: What happens if my health insurance company denied my request to see a specialist or to have a medical procedure?
Answer: You have the right to challenge the decision any time your health plan denies coverage for services that you and/or your doctor feel are medically necessary.
Most health plans have a medical professional that reviews your doctor's or other health care provider's request for care and services to ensure it is a covered benefit and that it is medically necessary and appropriate. This is referred to as "utilization review."
Question: What happens if my doctor requests pre-approval for a hospital admission, procedure or service?
Answer: Your health plan has 2 business days after receiving all information from your doctor to make a decision to approve or deny the request. The plan must notify your doctor of the decision to approve or deny your request within 1 working day by phone, and notify you by fax or in writing.
Question: What happens if the plan denies my doctor's request?
Answer: The plan must write, fax or e-mail you within 1 working day after making the decision. The notice of denial must include the main reasons for the refusal to pay for the treatment, how to initiate an appeal, and how to request a written statement of the clinical criteria used in the decision.
Your doctor has the right to talk to the plan doctor involved in the denial. Your doctor may ask for reconsideration of the decision, either orally or in writing. The health plan must make a decision within 1 working day after receiving the new request.
Question: What happens if I submit a claim for care or services already received?
Answer: Your health plan has 30 days after receiving all information to review the service and determine whether or not it was medically necessary. If the claim is denied, the plan has 5 working days after making its decision to tell you and your doctor in writing. The letter must include:
Question: What happens if I believe I have been inappropriately denied a benefit?
Answer: The appeals process is followed.