If we deny a claim and you do not agree, you can ask for a review. This is called an appeal. There are two ways to do this:
You may appeal on your own. You also may authorize someone to appeal for you. This is called an authorized representative.
You have 180 days from when you get the notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you a longer period of time.
How soon we respond may vary. It depends on a state law, whether your appeal is urgent or your plan offers one or two levels of appeal.
We make decisions for urgent care claims more quickly. If your doctor feels that a delay will put your health, your life or your recovery at serious risk or cause you severe pain, that’s an urgent care claim. You or your doctor may ask for an "expedited" appeal. Call the toll-free number on your Member ID card or the number on the claim denial letter.
What if your claim is still denied after your appeals? You may be able to have a third party (independent party) review your denied claim. This is called an external review.
The Affordable Care Act (ACA) created new rules for health plans. Now health plans that are subject to the law must include an external review process.