Health plan & appeal guide
An insurance company pays the claims, so your state’s insurance rules apply and your state can help overrule a wrong denial.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Your appeal
The insurance company on your card
UnitedHealthcareAetnaAnthemPriority HealthCignaKaiser PermanenteUPMC Health PlanMcs LifeTriple-S SaludGeisingerHealth NetMedical MutualDean Health PlanHMSA (Blue Cross Blue Shield of Hawaii)
Send it to the appeal address printed on your denial letter (or the back of your card). Appeals go to the insurer, not your employer.
Plan documents
The plan administrator
Ask in writing for the Summary Plan Description and the insurance certificate. Employer plans must send them within 30 days.
Dates you enter stay on this device.
File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.
If they say no again, request external review within 4 months of that final denial. It is run by the state where the policy was issued, usually your employer's home state (VA). The review is usually free. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.
If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.
External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.
If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.
Your employer pays the claims from its own money, so federal law (ERISA) applies — not your state’s insurance rules.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Your appeal
The claims administrator
Send it to the appeal address on your denial letter or the back of your card. This filing doesn't name the administrator; your card does.
Plan documents, and a copy of your appeal
The plan administrator
The plan administrator is legally responsible for the plan. Ask in writing for the Summary Plan Description and the plan document. The plan administrator must send them within 30 days, or a court can add a penalty of up to $110 a day.
Dates you enter stay on this device.
File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.
If they say no again, request external review within 4 months of that final denial. The plan must send it to an independent review organization it contracts with. Some states let self-funded plans use the state's program instead. Your denial letter has to tell you where to send it. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.
If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.
Call the Department of Labor's benefits advisors. They enforce these rules for employer plans and can contact the plan for you, free. After the appeals are finished, a lawyer can sue under ERISA if the denial was wrong.
External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.
If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.
Your employer pays the claims from its own money, so federal law (ERISA) applies — not your state’s insurance rules.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Your appeal
The claims administrator
Send it to the appeal address on your denial letter or the back of your card. This filing doesn't name the administrator; your card does.
Plan documents, and a copy of your appeal
The plan administrator
The plan administrator is legally responsible for the plan. Ask in writing for the Summary Plan Description and the plan document. The plan administrator must send them within 30 days, or a court can add a penalty of up to $110 a day.
Dates you enter stay on this device.
File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.
If they say no again, request external review within 4 months of that final denial. The plan must send it to an independent review organization it contracts with. Some states let self-funded plans use the state's program instead. Your denial letter has to tell you where to send it. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.
If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.
Call the Department of Labor's benefits advisors. They enforce these rules for employer plans and can contact the plan for you, free. After the appeals are finished, a lawyer can sue under ERISA if the denial was wrong.
External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.
If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.
Coming next
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