Expedited appeal

Waiting could seriously jeopardize your life, your health or your ability to regain maximum functionThat is the federal test for a claim involving urgent care.Or your doctor says the delay would cause severe pain the care would relieveA physician who knows your condition can make this statement, and the pain must be one that cannot be adequately managed without the requested care.Ask your treating doctor to say the claim is urgentIf a physician who knows your condition says it is urgent, the plan must treat it as urgent, and a plan that is not grandfathered must defer to your provider's determination.If a course of care the plan already approved is ending, ask at least 24 hours before it runs outAn urgent request to extend approved treatment must be decided within 24 hours if you make it at least 24 hours before the approval ends.If your health is in immediate danger, get emergency care firstA plan that covers emergency services must cover them without prior authorization, whether or not the hospital is in network.

Ask by phone or in writing, and use the word urgent or expeditedAn urgent appeal may be requested orally, so you do not have to wait to write a letter.Have your doctor make the request or support itIn an urgent case a health care professional who knows your condition must be allowed to act as your representative.Send records and your doctor's statement by fax or another fast methodThe plan and you may exchange information by telephone, fax or a similarly fast method in an urgent appeal.Write down who you spoke to, the time, and what they promisedIf the first answer is oral, the written notice must follow within 3 days, and your notes show whether it did.

The plan must decide within 72 hours at mostSeventy-two hours is a ceiling, not a target, and the plan must decide as soon as possible.If the plan says your urgent claim is incomplete, it must say what is missing within 24 hoursYou then have at least 48 hours to supply it, and the plan must decide within 48 hours after it receives the information or after your time to supply it ends.Ask for expedited external review at the same timeYou may request fast independent review while the fast internal appeal is still going if waiting would seriously jeopardize your life, health or ability to regain maximum function.Expect an expedited external review decision within 72 hours at mostIt must come as fast as your medical situation requires, with written confirmation within 48 hours if the first notice was not in writing.

Ask your doctor to restate the urgency in writing and send it againThe plan must treat the claim as urgent when a physician who knows your condition says it is.Contact the regulatorFor an employer plan call the Employee Benefits Security Administration at 1-866-444-3272, and for a plan bought from an insurer contact your state insurance department.Go to external review without waiting if the plan breaks its own rulesIf a plan that is not grandfathered fails to strictly follow the internal appeal rules, you may go straight to external review or to court.

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