Key points
- Your provider's appeal and your own appeal can be separate. Unless the plan confirms in writing that one counts as the other, protect your own.
- A plan must let an authorized representative act for you. In an urgent case it must let a health care professional who knows your condition do so.
- Send the plan and the office the same facts, and keep one shared record of what was filed, when and where.
When a plan denies care, two people may want to appeal: you, and the provider who ordered or gave the care. You are allowed to run both. The risk is not that two appeals are too many. The risk is that each side assumes the other has filed. Decide who files what, put it in writing, and keep your own appeal alive until the plan tells you in writing that the other one counts for you.
What this means
A patient appeal is your own request that the plan change its decision, using the appeal rights in your plan. A provider appeal is a request from the doctor, hospital or other provider. Some providers have their own appeal route set by their contract with the plan, and it may have its own forms and deadlines. We have no federal rule that tells you what those are. Ask the office what route it is using and what its deadline is.
The federal claims rule for group health plans lets you name an authorized representative, a person who acts for you in the appeal. That person can be a family member, a lawyer or your provider. Your plan may ask you to use its own form, so ask for it. In an urgent case, the plan must let a health care professional who knows your condition act as your representative.
What to do
- Ask the office what it plans to do (your step). Ask: “Are you appealing? Through which route? By what date? Will you send me a copy?” Write down the answers.
- Decide who writes the medical argument. The office is usually best placed to explain why the care is needed. You are best placed to describe what happens without it. See how to ask your doctor for a letter and the peer-to-peer call.
- Name your representative in writing if you want the office or someone else to act for you. Use the plan’s form if it has one. If it does not, the authorized representative designation is a plain letter. This is your signature, not your doctor’s.
- File your own appeal anyway if your deadline is near. Your deadline is on your denial notice. If the office is slow or unsure, do not wait. See how to file an internal appeal.
- Send the same facts everywhere. Use the same claim number, dates and description of the care in your letter and in the office’s. Different versions create room for the plan to say it needs clarification.
- Keep one log. Write down every filing, who sent it, the date, how it was delivered and the confirmation. The appeal tracker and the call log are built for this.
- Share every plan letter. Send the office a copy of each letter you receive, and ask them to do the same.
What the office may say, and what to say back
“We already appealed.” Ask for a copy of what they sent, the date, and how it was delivered. Ask whether it was filed as your appeal or the provider’s own, and whether the plan has confirmed that in writing.
“We do not do appeals for patients.” Ask for the diagnosis, the dates of service and the clinical notes, and ask for a short letter you can attach to your own appeal. The note to your doctor’s office shows how to ask.
“You will have to sign something first.” Ask for the form today. Your plan or the office may need your written permission before they discuss your case with each other.
The rule
A plan’s claims procedure must allow an authorized representative to act on behalf of a claimant in pursuing a benefit claim or appeal. In a claim involving urgent care, the plan must allow a health care professional with knowledge of the claimant’s medical condition to act as authorized representative. See title 29 of the Code of Federal Regulations (CFR), section 2560.503-1(b)(4).
Watch for
- Whose deadline. Your deadline to appeal is counted from when you received the notice. A provider’s deadline under its contract may be shorter. Do not assume the office’s deadline matches yours.
- Who gets the answer. The plan may send its decision to you, to the office, or to both. Ask each to forward anything they receive.
- Medicare Advantage and Medicaid. For a Medicare Advantage plan, the rules let the treating physician ask for a reconsideration after telling the member, and an expedited request can be made orally. Medicaid has its own rules. See Medicare Advantage appeals and Medicaid appeals and fair hearings.
- Billing. An office may bill you while its appeal is pending. See the bill while you appeal.
- Someone else’s appeal. If you are helping a parent, partner or friend, see how to act for someone else.
What next
- How to file an internal appeal: the steps for your own appeal.
- The peer-to-peer call: a short phone review between your doctor and the plan’s doctor, sometimes available before a formal appeal.
- How to get an expedited appeal: if a health professional says waiting could harm you.