The appeals process is different for non-grandfathered plans and grandfathered plans. If your plan was effective after the Affordable Care Act (ACA) was signed on March 23, 2010, or your plan existed before the ACA, but lost its grandfathered status at renewal, it is a non-grandfathered or “other” plan. These plans are required to offer an appeals process that complies with the ACA.
What does the appeals process for a non-grandfathered plan look like?
You must file your appeal with your health plan within the timeframe your plan requires. This will either be listed on the adverse determination, explanation of benefits or in your plan summary.
Here's how to appeal a health insurance denial. Once you file your appeal, your plan’s decision could come back in:
Timeframe | Type of appeal |
|---|---|
24 hours or less, but no more than 72 hours | If it is urgent |
| 14-60 days | Post-service claim |
14-30 days |
If you lose this first level of internal appeal and you have an individual plan, you may request an external review. If you have a group plan, your plan will notify you about what you can do if you would like to continue appealing. Some plans will offer another round of internal review; some will tell you how to file an independent review (leg.wa.gov); and for others it might mean pursuing legal action.
When can I request an external review from my health plan?
You can request an external review once one of the following occurs:
- You’ve completed the internal review.
- Your plan fails to return its decision in the time allowed.
- You have an extremely urgent issue and you request to have an external review at the same time as the internal review.
What can I expect from an external review?
- Your health plan will assign an Independent Review Organization (IRO) (leg.wa.gov) to review your appeal.
- It will notify you which IRO is reviewing your appeal, and give you five business days to provide any missing information or additional evidence.
- The IRO must notify you and your health plan of a decision within the timeframe allowed (see next table).
Timeframe | Type of situation or health plan |
|---|---|
| 72 hours | If it is urgent |
15 days, or 20 days after receiving all necessary information | Fully insured plans (offered by an insurance company) |
45 days |
If the IRO overturns the denial, the decision is binding to the health plan. If it upholds the denial, your only option at this point is to seek legal counsel.