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How to Appeal a Health Care Insurance Decision

A Guide for Consumers in Washington State

 

August 2011
Version 4.0

This guide was published with funds provided by The Affordable Care Act and administered by the U.S. Department of Health & Human Services

Table of Contents

• Commissioner's Letter
• Introduction
• Where to Start

Section A: Information about appeals

STEP 1: Identify your plan and status

1.1 Identify your type of insurance coverage
1.2 Identify if your issue is “pre-service” or “post-service”
1.3 Is your issue urgent?
1.4 Accidental billing error or intentional denial?
1.5 What does your plan cover?

 

STEP 2: Learn who regulates your health plan and what to do once you’ve decided to appeal

2.1 Different plans have different regulators
2.2 Chart: Which law does your plan follow?
2.3 Where to find appeals information for plans not subject to state or federal requirements
2.4 What to do before you file your appeal.
2.5 Gather all necessary documents

 

STEP 3: The appeal process – for grandfathered or non-grandfathered (“other”) plans

3.1 Information about filing your appeal
3.2 Overview of the appeal process for grandfathered plans
3.3 Overview of the appeal process for non-grandfathered (“other”) plans

 

STEP 4: Increase your chances of winning your appeal

4.1 Tips for drafting your appeal
4.2 Things to avoid when drafting your appeal
4.3 Summary of recommended best practices and tips- for all types of health coverage
4.4 Tips for writing a good appeal letter

• Sample Templates & Letters

Section B: Appeals Tracks & Additional resources

• Go to Section B
• Appeals Tracks
• "Keeping track of your communications" log
• Your “Important Information” Worksheet
• FAQ about Washington state laws
• Glossary of terms
• List of additional agencies, websites, and places for you to use as a resource

Information provided in this guide is intended to be general summary information to the public. It’s not intended to take the place of either the written law or regulations.

 

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Updated 10/11/2011