STANDARD APPEAL PROCEDURE

If you are not satisfied with your health plan's decision, you have the right to appeal. All health plans must have written procedures for dealing with appeals. Most plans require that the request be in writing. For details, check your membership booklet or policy under "Grievance Procedure."

First Level Appeal

A Doctor who was not involved in the first decision to deny your claim must evaluate your appeal.

The plan's letter telling you of the appeal decision must be sent to you within 20 days of the appeal request. The letter must include:

  • The name, title and qualifications of the doctor who evaluated the appeal.
  • The reviewer's statement of the reason for the appeal.
  • The medical reason for the decision.
  • How to file a second level appeal.

Second Level Appeal

If you are not satisfied with the first level appeal decision, you can request a second level appeal as described below:

  • The health plan must appoint a second level grievance review panel of at least three people. A majority of the members must be professionals with the appropriate expertise who were not involved in the original denial, are not employees of the health plan, and do not have a direct financial interest in the outcome.
  • The panel must hold a meeting to review your second level appeal within 45 days of your appeal request.
  • You have a right to, but need not appear in person before the panel. If you live too far away, the plan must pay for you to present your case by conference call, video conferencing, or other technology.
  • You have the right to present supporting material in writing before, and at the hearing. You also have the right to be assisted by a person of your choice.
  • You must be notified in writing of the review date at least 15 working days before the review.
  • The health plan must provide you with all relevant information that is not confidential.
  • The plan must notify you of the panel's decision within 5 working days of the review meeting. The letter must include:
    1. The names, titles and credentials of the panel members.
    2. Panel member's summary of the reason for the decision, including reference to any evidence or documents considered by the panel.
    3. The medical reason for the decision.
    4. Notice of any additional appeal rights, including your right to contact the Colorado Division of Insurance.

MEDICARE AND MEDICAID

Medicare has a different set of rules for appeals. The above requirements do not apply. Call the Division of Insurance to find out about Medicare's rules at 1-800-930-3745.

People on Medicaid have different appeal rights. Call Medicaid at 1-800-221-3943 or 303-866-3513, or refer to the section about Medical Appeals in the table of contents on the website, www.dora.state.co.us/insurance

Question: What role does the Division of Insurance play in the appeals process?

Answer: WHEN THE DIVISION OF INSURANCE CAN HELP YOU!

If you have completed your health plan's first and second level appeals and you are still not satisfied, you can contact the Colorado Division of Insurance. You are also welcome to contact the Division for clarification of the process.

File a complaint by writing a brief letter stating the facts of the case and send the letter to:

Colorado Division of Insurance
1560 Broadway, Suite 850
Denver , Colorado 80202
Phone: (303) 894-7490
1-800-930-3745

It is important for you to complete your insurer's appeal process before contacting the Division of Insurance with your complaint, unless it is for clarification of your rights. If you have not completed this appeal process, the Division will refer you back to your plan.

The Division of Insurance can help you:

  • Record your complaint against the health plan.
  • Thoroughly investigate your complaint.
  • See that you get clear answers to your questions.
  • Make sure the health plan follows states' law.

The Division of Insurance cannot:

  • Force a favorable decision if the law and facts are not on your side.
  • Require your plan to pay for services that are excluded by the policy.
  • Provide legal services that are sometimes needed to settle complicated problems.

External Review

Effective June 1, 2000, if you are not satisfied with the second level decision, you can apply for an independent external review within 60 days of the final health plan denial. An independent external review entity (currently a function of the Colorado Division of Insurance) will be assigned by the Division of Insurance. The external review findings will be provided within 30 working days and will be binding on both the carrier and the consumer.

 

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