How to get an expedited appeal

If waiting for a normal appeal could seriously harm you, ask for an expedited (fast) appeal. Ask by phone and in writing, and have your doctor say plainly that the case is urgent. The plan must decide as soon as possible and no later than 72 hours after it receives the appeal. For a plan that has outside review, you can ask for that review at the same time.

What this means

“Urgent” has a specific meaning in the federal rules. A claim involves urgent care when the normal time limits could seriously jeopardize your life, your health or your ability to regain maximum function. It is also urgent if a physician who knows your condition says that, without the care, you would have severe pain that cannot be adequately managed.

Your doctor’s word carries weight. If a physician who knows your condition says the claim is urgent, the plan must treat it as urgent. Plans and insurers that are not grandfathered “shall defer” to your attending provider’s decision. A grandfathered plan (one in place since March 2010 that has kept its old status) still has to treat the claim as urgent when such a physician says so.

The 72 hours is a ceiling, not a target. The plan must decide “as soon as possible”, and 72 hours is the longest it may take.

What to do

1. Tell the plan the case is urgent (your step, today). Call the number on your denial notice. Say: “I am asking for an expedited appeal. My doctor says waiting could seriously harm my health.” Ask for a reference number and the name of the person.
2. Ask your doctor to say so in writing (your doctor’s step). The doctor’s short statement should say what the condition is, what the denied care is, and why waiting for a normal timeline could seriously harm you or leave you with severe pain that cannot be managed. The urgency certification letter is a form your clinician can use. Do not write the medical statement for them.
3. Send the written appeal the same day. Use the expedited appeal letter. Send it by fax or through the plan’s portal if it offers one, and keep the confirmation. An urgent appeal may be requested orally or in writing, and information may move by phone, fax or similarly fast methods.
4. Let your doctor act for you if that is faster. In an urgent case the plan must allow a health care professional who knows your condition to act as your authorized representative.
5. Ask for outside review at the same time, if the plan has it. You may request expedited external review while the expedited internal appeal is still open when waiting for the internal appeal would seriously jeopardize your life, health or ability to regain maximum function. See how to request external review.
6. Write down the time you asked. Count 72 hours from then. If nothing arrives, call, then use the steps in when the plan goes silent.
7. Ask the doctor to call the plan’s reviewer. A peer-to-peer call can sometimes resolve a case quickly, but it does not replace the appeal. File the appeal first.

What the plan may say, and what to say back

“This does not qualify as urgent.” Ask who decided that and on what basis. Send your doctor’s statement that the case is urgent and cite the rule below. A plan must treat a claim as urgent when a physician who knows your condition says it is.

“We will decide in four business days.” The federal rule for an urgent appeal is 72 hours at the most. Some agency pages say four business days. Where sources differ, use the stricter one and ask for 72 hours.

“Please send your appeal in writing and we will start the clock when we have it.” An urgent appeal can be made by phone. Send the writing too, but ask the plan to log the time of your call as the start.

The rule

A “claim involving urgent care” is one where the normal time limits could seriously jeopardize the claimant’s life, health or ability to regain maximum function, or, in the opinion of a physician with knowledge of the claimant’s condition, would subject the claimant to severe pain that cannot be adequately managed without the care. If such a physician says the claim is urgent, the plan must treat it as urgent. An urgent appeal must be decided no later than 72 hours after the plan receives it. See title 29 of the Code of Federal Regulations (CFR), section 2560.503-1(m)(1) and (i)(2)(i).

Watch for

• If the plan says no to urgent, keep going. Ask for the refusal in writing, and file a normal appeal at once so you do not lose time.
• Incomplete requests. When you first ask for an urgent claim decision, the plan must tell you within 24 hours what is missing, give you at least 48 hours to supply it, and decide within 48 hours after receiving it.
• Urgent denials may start by phone. The plan may give an urgent denial orally first, but a written or electronic notice must follow within 3 days and describe the fast review process.
• Not every plan has outside review. Grandfathered plans have no general federal outside review (apart from surprise-billing disputes). The Affordable Care Act appeal and external review rules and the No Surprises Act do not apply to short-term plans, health care sharing ministries and fixed indemnity products. If a fixed indemnity plan comes through an employer, ask whether the general federal claims rule for employer plans applies; we have not confirmed that. Your notice or plan document is the guide.
• Medicare Advantage. A Medicare Advantage plan must give an expedited decision within 72 hours when the member’s physician says the standard time could seriously harm the member. See Medicare fast appeals.
• Medicaid. An expedited state fair hearing on a service decision must come no later than 3 working days (in managed care, 3 working days after the state gets the case file from the plan). See Medicaid appeals and fair hearings.
• Deadline on your notice. Times for public programs vary. Check the date on your notice, which controls.

What next

• Keeping treatment going during an appeal: what to ask if care has already started and the plan is ending it.
• How to request external review: how to ask for expedited independent review.
• When the insurer misses its deadline or goes silent: what to do if 72 hours pass with no answer.