Coverage Appeals

Key findings used in wiki

• CMS distinguishes appeals of private health-plan or issuer coverage decisions from Marketplace eligibility appeals.
• A denial notice must identify the claim and explain the reason, relevant codes and standards, available appeal processes, and how to initiate an appeal; internal guidelines and medical-necessity reasoning must be supplied or made available without charge.
• Consumers generally have 180 days after receiving a denial to file an internal appeal and may submit additional information, including a letter from a doctor.
• Consumers should keep denial and EOB documents, copies of appeal materials, authorized-representative forms, and dated notes from related calls.
• A consumer may authorize a caregiver, clinician, advocate, or other representative to file an appeal using the plan or issuer authorization process.
• When the standard timeline could seriously jeopardize life, health, maximum function, or adequate pain management, an expedited internal appeal may be requested and an expedited external review may begin at the same time.
• After an internal denial, eligible consumers may request independent external review through the applicable state or federal process; the plan or issuer must accept a decision that overturns the denial.
• Standard external review must be completed as soon as possible and no later than 45 days after receipt; expedited external review must be completed as the medical situation requires and no later than 72 hours.
• A Consumer Assistance Program may help a consumer file an appeal or act on their behalf.