Health plan & appeal guide
This employer has both kinds of coverage. The company on your insurance card decides which rules apply to you.
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.
It’s printed on the front of the card. The filing shows which companies sell insured options here and which ones run the self-funded plan.
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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
Blue Cross Blue ShieldHighmarkPersonal Choice Pre 65Keystone Health Plan East Early RetireeKeystone Health Plan East Keystone 65Personal Choice 65Ah Hmo, Inc., Pa Early Ret
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 (PA). 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.
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
Triple-S Salud
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 (PA). 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.
Coming next
We’re building a tool that drafts your appeal from the denial letter and keeps track of every deadline. Leave your email and we’ll send one note when it’s ready.