First 48 hours after a denial

Find the date on the letter and the date it reached youAppeal deadlines count from a date, and a group health plan must give you at least 180 days after you receive the denial notice, so write down both dates and check the date on your notice, which controls.Find the reason the plan givesA denial notice must state the specific reason or reasons and the plan provisions the plan relied on.Check that it is really a denialAn Explanation of Benefits (the statement your plan sends after a claim) is not a bill, and your usual deductible or copay is not a denial.Note whether care you already have is being cut shortIf your plan approved a course of treatment and now ends it early, that is a denial too, and the plan must give you notice early enough to appeal before the benefit ends.

Do not pay the provider until the claim is finalAn Explanation of Benefits is not a bill, so wait until the claim decision is final before paying.Ask the provider's billing office to hold the accountThe billing office controls when a bill goes to collections, so ask for a hold while the claim is disputed and write down who agreed and when.Keep the envelope, emails and portal screenshotsYour deadline counts from when you receive the notice, so the receipt date is evidence you may need.

Ask in writing for your claim fileYour plan must give you, free of charge, the documents, records and information relevant to your claim, and a written request gives you a dated record.Ask for the diagnosis code, treatment code and denial codeA plan that is not grandfathered must give you these codes and their meanings on request, and asking for them is not treated as filing an appeal.Ask for the guideline or clinical reasoning the plan appliedIf the plan relied on an internal rule or on a medical judgment, it must either explain it or give you a free copy on request.Ask your employer's plan administrator for the plan document in writingFor an employer plan covered by the Employee Retirement Income Security Act (ERISA), the administrator must furnish the summary plan description on written request.

Call your doctor's office and say you received a denialYour doctor can ask for a peer-to-peer review (a call between your doctor and the plan's reviewing doctor), and the office can tell you whether a billing error is the cause.Find out whether your employer plan is self-funded or bought from an insurerAsk your human resources department, because the answer decides whether your state insurance department or the federal Department of Labor is your regulator.Note the state consumer help contact on the noticeA non-grandfathered plan must put contact details for a state consumer assistance program or ombudsman in the denial notice.

First 48 hours after a denial

Sources