Health plan & appeal guide
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 fund office (Board of Trustees)
Union funds decide appeals through the trustees. If your denial letter gives a different appeal address, use that one.
Prescription denied?
The pharmacy benefit manager
CVS CaremarkOptumRx
Drug denials usually come from the pharmacy benefit manager, and the appeal goes to the address on that denial.
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.
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
Anthem
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 (WI). 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.