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Understanding your health plan’s internal appeals process

On Behalf of | Oct 12, 2018 | Delayed And Denied Insurance Claims | 0 comments

As a Texas resident with a health insurance policy, you have the right to question your insurer’s decisions if the company denies you coverage or decides to terminate your relationship. The first step in the process involves requesting what is known as an “internal review.” Attorney Jon Michael Smith is well-versed in the methods health insurers often use to deny claims, and he has helped many clients facing similar circumstances pursue appeals and other solutions to meet their needs.

According to HealthCare.gov, your health insurer may deny your claim for any number of different reasons, but you are within your rights to question, and if necessary, appeal, your health insurance company’s decision to deny you coverage. Your insurer may, for example, deny your claim if you had what it considered to be a “preexisting condition,” meaning you had the issue before your insurer started covering you. It may do the same if it considers certain treatments not medically necessary or experimental in nature, among other reasons.

Once you receive word of your denied claim, which your insurer must issue within a particular timeframe, you can decide whether to move forward with requesting an internal appeal. Please note, however, that the exact amount of time your insurer has to respond to you, in writing, depends on the nature of your request for coverage. Before filing your appeal, however, you will need to get certain ducks in a row.

First, you will need to fill out any forms your health insurer requests from you, and you will also want to submit any documentation you have about your condition from your doctor. Typically, you have 180 days from the day you received word about your denied claim in which to move forward with an appeal. If your internal appeal proves unsuccessful, you may be able to find success through requesting an external review. You can find more about denied insurance claims by visiting our webpage.