When you’re sick, the last thing you want to hear is that your insurance company has rejected your medical claim.
But if your insurer denies coverage, the Affordable Care Act guarantees you certain protections:
|You have the right to appeal your insurer’s decision.|
| Your insurer must inform you of:
|Your insurer cannot drop your coverage or raise your premium because you appealed a claim decision.|
(NOTE: Only non-grandfathered health plans — those with an effective date on or after March 23, 2010 — are required by law to offer these protections.)
The first step in the appeal process is to file an internal appeal in which you ask the insurer to reconsider its decision to deny coverage or treatment.
If the insurer does not reverse its decision after the internal appeal, you have the right to an external review. This involves an independent party reviewing the decision.
If the denial is overturned by the independent party, the insurer must comply and approve the claim.
Things You Can Do to Lessen the Chance of a Denial
Although filing an appeal is within your rights, the hassle factor of doing so is worth trying to avoid a denial in the first place. Here are some things you can do:
- Understand and follow the descriptions of your plan. Ask before having a procedure whether or not it will be covered and how much you will need to pay out of pocket.
- Know the rules. If your insurance company requires pre-authorization for a treatment or service, make sure you get it. Ask for your doctor’s assistance in demonstrating to the insurance company that a procedure is medically necessary.
- Stay in network. Care received out-of-network may not be covered, or may be covered at a lower rate, meaning you will pay more.
- Verify all documentation. When you receive any paperwork from the insurance company (for example Explanation of Benefits), review it carefully to make sure everything is complete and accurate. If a medical provider gives incomplete or wrong information, this could result in a denial.
- Keep accurate records. Having proper documentation, including notes from any phone calls you may have, is key, especially if you do need to file an appeal.
Getting Help with Your Appeal
Virginia Medical Plans is available to assist with any issue that arises with your coverage — including claims denials — if we helped you enroll in your coverage.
If you got your coverage through us, please reach out by phone 1-800-867-0800 or email [email protected] to learn how we can help.
You may also find useful information through your state’s bureau of insurance:
- In Virginia: Consumer Assistance and Outreach Services Brochure
- In Maryland: Your Rights When Your Health Insurer or HMO Will Not Pay for Health Care Services
- In the District of Columbia: DC Department of Insurance, Securities and Banking