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Transcript:
Welcome to Health Care Reform Demystified. Today’s episode? Upon Further Review: Appeals Under the Affordable Care Act.
[host appears in referee’s uniform]
Run, run, run, run!
It’s often said that baseball is a game of inches. But if you ask me, football also deserves that distinction. The final score of a game often comes down to what side of a white chalk line a player is on.
It’s the job of the humble referee to sort things out. And sometimes a coach will disagree with a close call. In professional football the coach can challenge a call by throwing a red flag like this [throws red flag].
At this point the referee confers with other officials to review the play and make sure the right call was made.
The Affordable Care Act includes provision that offers health plan members a process similar to the coach’s challenge in football. If your health plan denies payment for a treatment that you believe should be covered, you have the right to challenge that decision and appeal it.
Let’s take a closer look at this provision and how it works. Before we begin, please note that the parts of the health care law covering appeals apply only to health plans or policies that were new or renewed after September 23, 2010. Plans created on or before this date may be grandfather plans, which are exempt from some of the provisions of the Affordable Care Act, including this one. See my video on grandfather plans for more on that subject.
For non-grandfather plans, if your plan denies payment in whole or in part for a service or a treatment, you have the right to appeal its decision. Here’s how that process works. When you use your insurance to obtain a medical service or treatment, the claim is submitted to your plan.
If your plan denies payment in whole or in part for that claim, it must provide you with certain information, such as:
- The reason your claim was denied
- Your right to file an Internal Appeal
- That you may have the right to request an External Review
- The availability of, and contact information for, health insurance consumer assistance (if your state has such services)
Let’s say that this happens to you and you decide to file an Internal Appeal following the process outlined by your plan. Once you make your request, the law also how quickly your plan must respond.
Some health care services aren’t planned in advance or scheduled. If your claim involves an urgent care service or treatment, your plan must issue a decision on your appeal within 72 hours if all relevant information is provided at the time of the initial request.
It’s worth noting that in such cases, the attending provider decides whether or not the service provided qualifies as urgent care—not the health plan.
For health care services that don’t involve urgent care, the process is the same but the timeline is different. If you receive non-urgent treatment that your plan denies payment for in whole or in part, your appeal must generally be decided within 30 or 60 days, depending on the number of internal appeals allowed by your plan.
Finally, let’s say that you or your doctor request coverage for a treatment or service before you actually receive it, and your plan denies that request in whole or in part. The law requires that your plan issue a decision on your appeal within 15 or 30 days, depending on the number of internal appeals allowed by your plan.
[blows whistle, throws red flag]
Now, as the name suggests, the internal appeal is a process conducted internally by the health plan. If after the internal appeal process the plan still denies a request for payment or services, you may have the right to request an independent external review. Since the external review process may vary by plan and by state, your appeal determination letter will contain specific information about how to request such a review.
Under the Affordable Care Act, these rights took effect when your non-grandfather plan started a new plan year or policy year on or after September 23, 2010.
[blows whistle]
Your health plan is designed to help you access covered benefits, treatments and services. The Affordable Care Act provides a way for you or your authorized representative to make sure that covered services are appropriately reimbursed. And when you think about it, your right to an appeal is like health coverage. Even when you’re not using it, you’ll feel that much better knowing it’s there.
Now, if you’ll excuse me, it’s time to practice my hand signals.
You can find more answers to questions about the Affordable Care Act on the United for Reform website: uhc.com/reform. And as always, contact your broker or UnitedHealthcare representative with any questions about your plan.
Health Care Reform Demystified
Health Care Reform Demystified: Filing an Appeal
With U. Horace Cartwright
If your health plan denies payment for a service you believe should be covered, you can challenge that decision under the Affordable Care Act. Learn about your right to appeal in this video.
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