Your rights when a health plan says no

A denial is not the final word. If you have a job-based plan or a plan you bought yourself, federal rules give you a set of rights after a denial, and Medicare, Medicaid and other programs have their own. These rights are minimums. Your plan document or state law may give you more. A few kinds of plan give you less.

What this means

If you have a job-based or individual plan

• A written reason. The denial notice must be “calculated to be understood by the claimant” and state the specific reasons and plan provisions relied on.
• To see the file. On request and free of charge, you may see and copy everything relevant to the claim, including documents the plan considered even if it did not rely on them, and the identity of medical experts it consulted.
• At least 180 days to appeal, counted from when you receive the notice. No fee to file a claim or appeal.
• A fresh look. The appeal must give no deference to the first decision and be decided by someone who was not involved in it. If the denial rests on a medical judgment, a health care professional with the right training must be consulted, and that person cannot have advised on the first decision.
• To send your own evidence. Comments, documents and records. The reviewer must consider them, including material not before the first decision.
• To hear the plan’s new reasons. Non-grandfathered plans must give you, free, any new evidence or new rationale before a final internal denial, early enough to respond.
• Deadlines for the plan. Urgent decisions: as soon as possible and no later than 72 hours. For the first decision, 15 days before care or 30 days after care, with limited extensions. For an appeal, 30 days before care or 60 days after care, or half of those days at each level if the plan has two levels. An urgent appeal is still 72 hours at each level.
• A decision before treatment is cut. If a plan cuts short a course of care it approved, it must give you notice early enough to appeal and get a decision first.
• Independent review. After the internal appeal, non-grandfathered plans must offer external review with at least four months to ask. Under the federal process it is free, and its decision binds the plan.
• A representative. You may name someone to act for you. In an urgent case a health care professional who knows your condition must be allowed to.
• Emergency care. Judged by whether a prudent layperson, with average knowledge of health and medicine, could reasonably expect serious harm without immediate care, based on symptoms rather than diagnosis.

If you have another kind of coverage

• Original Medicare. The Medicare Summary Notice gives reasons and explains how to ask for a first appeal. There are five levels of appeal.
• Medicare Advantage. Plans must follow Original Medicare’s coverage rules, and cannot use their own criteria except where Medicare’s are not fully established.
• Medicaid. The state must tell you in writing the reasons, the regulations relied on and your right to a hearing, and generally must give 10 days’ notice before ending or cutting services.
• TRICARE, Veterans Affairs and others each have their own steps. See appeal deadlines by coverage type.

What to do

1. Find which list applies to you. Use the coverage type finder.
2. Use the right to see the file. Ask in writing with the claim file request. It costs nothing and tells you what the plan relied on.
3. Put the deadline in your calendar and use the deadline calculator. Check the date on your notice, which controls.
4. Ask for a fast decision if the case is urgent, with your doctor’s support. See expedited appeals.
5. Keep copies and a log of every request and reply.

What the plan may say, and what to say back

“You have already used your appeal.” Ask: “How many internal levels does my plan have? I am entitled to external review after the final internal denial.”

“Those documents are confidential.” Say: “I am requesting all documents relevant to my claim, as the claims regulation allows. Please reply in writing.”

The rule

A plan must give a full and fair review: the appeal gives no deference to the first decision, is decided by someone who is neither the person who made it nor that person’s subordinate, and the reviewer considers all the comments, documents and records you submit. Source: Code of Federal Regulations (CFR) Title 29, section 2560.503-1(h), the federal claims regulation.

Watch for

• Some plans have fewer rights. The Affordable Care Act appeal rules do not apply to short-term plans, health care sharing ministries and fixed indemnity products, and we have not confirmed whether the general federal claims rule for employer plans covers a fixed indemnity plan that comes through an employer. Grandfathered plans (in place on 23 March 2010) lack the general external review and the extra items, and a grandfathered policy you bought yourself may have only what its contract and state law give. See other coverage with fewer rights.
• Federal rules are floors. Plan documents and state law can give you more.
• Rights are not results. These rights give you a fair process, not a guaranteed outcome.
• Itemized bills. We found no general federal right for insured patients to an itemized bill. You do have the right to your plan’s claim records and to your provider’s billing records under the health privacy rules.
• When to ask for a lawyer. For lawsuits or deadlines you are unsure about, talk to a lawyer or a free legal aid service.

What next

• See what the notice must say: what a denial letter must tell you.
• Get the file: how to request your claim file.
• Learn the independent review: how external review works.
• Go to the topic page, read your denial letter.