Keeping treatment going during an appeal

A plan that has already approved your treatment and then wants to reduce or end it has made a denial, and the federal rules give you more protection than for a first-time denial. The plan must tell you early enough that you can appeal and get an answer before the care changes, and a plan that is not grandfathered must keep covering the care while the appeal is decided. These protections only work if you act as soon as the notice arrives.

What this means

Lawyers call this “concurrent care”: a course of treatment that was approved and is still going, such as a set number of therapy sessions, a hospital stay, home health visits or a long-running infusion. If the plan then cuts the course short or lowers the benefit, that is an adverse benefit determination, the official term for a denial, reduction or termination of a benefit.

The rule is built around timing. The plan must notify you far enough ahead that you can appeal and receive a decision before the benefit is reduced or ended. A different situation is an approval that simply runs out while your doctor wants the care to go on. That is a request to extend, with its own fast deadline (see step 5).

These protections come from federal rules for private plans. They do not cover Medicare, Medicaid or military coverage, which have their own notices and fast-appeal steps. See Medicare fast appeals and Medicaid appeals and fair hearings.

What to do

1. Read the notice for the end date. Find the date the plan says your care or benefit will stop. Write down the date you received the notice. See how deadlines are counted.
2. Appeal at once, and say you want care to continue. Use the plan’s phone number and send a letter the same day. State that you are appealing a reduction or ending of approved treatment and that you ask the plan to continue coverage until the appeal is decided. The continuing care appeal letter has wording for this.
3. Ask for an expedited appeal if stopping could seriously harm you. If your doctor says waiting could seriously harm your health or ability to regain function, the case is urgent and must be decided no later than 72 hours after the appeal arrives. See how to get an expedited appeal.
4. Ask your doctor for a short statement (your doctor’s step). It should say why the treatment is still needed and what is expected if it stops. Your doctor may also be able to speak with the plan’s reviewer by phone. The doctor letter kit can help.
5. If your approved treatment is about to run out, ask for an extension now. An urgent request to extend an approved course of treatment must be decided within 24 hours if you make it at least 24 hours before the approved treatment ends. Make it as early as possible, not at the last hour.
6. Ask about outside review. If the plan upholds the cut, a final internal denial about a continued stay, or about an admission or availability of care, can go to expedited external review. See how to request external review.
7. Ask in writing about money. Ask the plan to confirm whether you could be billed for care received while the appeal is pending if you lose. We found no federal rule that answers that question, so get the plan’s answer in writing and read the bill while you appeal.

What the plan may say, and what to say back

“The approval period ended.” Ask whether it is a new decision to stop or deny further care. If the plan is declining more care than it approved, that is a denial you can appeal. If your doctor needs more time, ask for an extension and note when you asked.

“Coverage stops on the date in the letter. You can still appeal.” Ask in writing for coverage to continue until the appeal is decided. Cite the rule below. Ask the plan to say which plan document or rule it is relying on if it refuses.

“Your doctor’s request came in too late.” Ask for the date and time it was received, and for the time limit the plan says applies. If you asked at least 24 hours before the approval ended, an urgent request for an extension must be decided within 24 hours.

The rule

If a group health plan has approved a course of treatment to be provided over a period of time or number of treatments, a reduction or termination before the end of that period or number is an adverse benefit determination. The plan must notify the claimant far enough in advance to allow the claimant to appeal and receive a decision before the benefit is reduced or terminated. A plan or insurer that is not grandfathered must provide continued coverage pending the outcome of an appeal on these terms. See title 29 of the Code of Federal Regulations (CFR), section 2560.503-1(f)(2)(ii) and 29 CFR 2590.715-2719(b)(2)(iii).

Watch for

• Grandfathered plans. A grandfathered plan is one in place since March 2010 that has kept its old status. If it is an employer plan, it still follows the timing rule for approved treatment under the Employee Retirement Income Security Act (ERISA), the federal law for employer plans. The separate requirement to keep coverage going while an appeal is decided is stated for plans and insurers that are not grandfathered. Your plan document says which you have.
• A provider leaving the network is different. If your doctor or hospital leaves your plan’s network, a “continuing care patient” (someone with a serious and complex condition, in inpatient care, scheduled for non-elective surgery, pregnant or terminally ill) may elect to keep in-network terms with that provider for up to 90 days. This is not an appeal. Ask the plan for a continuity of care request form. See out-of-network denials.
• Prior approval that could not be obtained. A plan cannot deny a claim for lack of prior approval where getting approval was impossible or could seriously jeopardize life or health, for example when the patient is unconscious.
• New information. Before a final internal denial, a plan that is not grandfathered must give you any new evidence or reason it relied on, free of charge and early enough for you to respond. Read each plan letter the day it comes.
• Do not rely on a promise by phone. If a plan agent says care will continue, ask for it in writing, with the date.
• Your deadline still applies. Appeal within the time on your notice. Check the date on your notice, which controls.

What next

• How to get an expedited appeal: the fastest route and what your doctor needs to say.
• How to request external review: the independent step if the plan says no again.
• The bill while you appeal: what to do if a provider bills you for care during the appeal.