Fight a denial

If your health plan refused to pay for a medical service or denied a prior authorization request, you have the right to fight the denial through your plan’s appeal process. But before you file your appeal, there is some information you need to know. Start by figuring out why your claim was denied. Check the reason code on the Explanation of Benefits (EOB) or the reason given on your denial notice. Below are some common reasons why a service may be denied and information you may need to file an appeal. Also, at the end of this section, you will find Do-it-Yourself appeal guides that you can use to file a first level appeal.

Why would the health plan deny all or part of a service?

There are many reasons why a health plan may not pay for a medical service. To find out the reason, you should look on your Explanation of Benefits (EOB) or denial notice. Some common reasons are below:

• No pre-authorization: Most health plans have rules for accessing care. Some plans require a referral or prior authorization (sometimes known as “prior approval”) before they allow you to get a specific service or see a specialist. They may deny your claim if you did not follow their rules. Consult your member handbook for your plan’s rules on accessing care.
• Not Medically Necessary: Each plan has its own definition of what is medically necessary. For most plans, medically necessary care does not mean the best possible care, but care that meets the standards of good medical practice for treating a particular condition. For this type of denial, your plan determined that there were not enough medical records to support payment of your claim or that you do not meet the plan’s medical criteria for coverage. This can include services that the plan may consider investigational or experimental. This process is called Utilization Review.
• Not a Covered Benefit: The denied claim may include a benefit that is not covered by your plan—this is sometimes called an “exclusion.” Your plan will not pay for services that are not covered, even if you have out-of-network benefits. You may be responsible for the cost of the service. Check your member handbook or ask a plan representative to verify what your plan covers.
• Out-of-network: If you receive services from an out-of-network provider, your plan may deny all or part of your claim. Many types of insurance allow enrollees to get care out-of-network only in an emergency or if their plan determines that they do not have the provider or offer the service that the enrollee needs. If you have out-of-network benefits for routine care, your health plan will only pay a portion of the out-of-network provider’s charge. This is called the “allowed amount.” You may be responsible for the balance. If you think that the amount your plan paid is too low, please see our Out-of-Network Reimbursement Do-It-Yourself guide below. Also, many types of insurance have balance billing protections or prohibitions. For more information on how to dispute a medical bill, click here.

What if my claim was denied as out-of-network after I received network directory misinformation?

If you received misinformation about the provider’s in-network status and your claim was denied as out-of-network, you should dispute the denial with your health plan. Many plans are required to regularly check that its providers are still in-network and update their provider directory within 15 days of a change. Plans must offer enrollees the opportunity to file an appeal under these circumstances. For more information on how to dispute a bill based on network directory misinformation, please read “Information your plan must give you under the No Surprises Act“.

The No Surprises Act protects against surprise bills if you were billed after getting incorrect information about your provider’s network status from your health plan’s directory. You should only be billed for the cost-sharing or deductible you would have been responsible for if the provider had been in-network with your plan. Like with any other surprise bill, you should use your plan’s appeals process to dispute the bill. If the plan still denies coverage, submit a complaint to CMS about the incorrect information in the plan’s directory.

Under NYS law, if you have a fully insured plan, you will only be responsible for in-network cost sharing if you got out-of-network care because of an inaccurate provider directory. Appeal with your plan, and if that does not resolve the issue, submit a complaint to DFS.

Provider directory misinformation happens when:

• An OON provider is wrongly listed as an INN provider in the plan’s online provider directory;
• An OON provider is wrongly listed as an INN provider in the plan’s hard copy provider directory and the directory was wrong as of the date it was published;
• The plan tells a consumer in writing that a provider is INN when the provider is not INN when they ask for this information over the telephone; or
• The plan doesn’t provide the network status of a particular provider in writing within one business day of the consumer’s request for this information by telephone.

If your plan denies your claim for any other reason not mentioned above, please contact CHA at 888-614-5400.

What are my appeal rights?

If you believe that your plan was wrong to deny your claim, you may have the right to appeal your plan’s decision. Different plans have different timeframes and rules for appealing. After you have determined why your claim was denied, you can find information about how and when to file an appeal on your EOB, your denial notice, and in your member handbook.

Do not delay! You have limited time to appeal your plan’s decision.

How should I prepare to file an appeal and what should I include with my appeal?

Read through any notices you received from your insurance company, and, if you need to, call your plan. After you understand why your claim was denied, gather the documents you need, which may include notices from your plan, parts of your plan contract or member handbook, or your medical records. Ask your provider for help! Your provider may be able to resubmit your claim, help you gather medical records, or write a letter of support. When writing your appeal, be sure to reference and address the specific reason given on the EOB or denial and explain why you think your plan should have paid your claim.

How much time do I have to file an internal appeal?

Many plans give 180 days to file a first level internal appeal, but some only give 60 days. While your first level internal appeal can be done on the phone, we recommend that you file your appeal in writing and keep a copy of everything you send to the plan and the date on which you sent it.

What if I have already appealed?

If you have already begun the appeals process, make sure you know where you are in the process. Most plans have 30 or 60 days to make a decision, depending upon the type of appeal, and must offer at least one level of internal appeal. Your additional appeal rights depend on the type of plan and type of denial you have. If your claim was denied as not medically necessary after Utilization Review, you may have the right to an External Appeal, an independent medical review of your health plan’s decision with an Appeal Agent.

You also have the right to file a grievance or a complaint about any action your plan or its providers took that you disagree with.

Who can I call to get help with filing my appeal?

If you need help appealing the denial of a claim or filing a grievance or a complaint, please contact CHA at 888-614-5400. For help filing your first level appeal, use our Do-It-Yourself appeal guides using the links below. If you are filing a second level or external appeal, please contact CHA as soon as possible.

• Medical Necessity DIY: Download the PDF
• Medical Necessity DIY (Spanish): Download the PDF
• Not a Covered Benefit DIY: Download the PDF
• Out-of-Network Reimbursement DIY: Download the PDF