If your health insurer won’t pay for a treatment or a bill, you do have options, appeal rights when your health insurer says no.
You can win an appeal, but it takes some work. First, read the denial letter. Why did they deny coverage? How do you appeal? How long does the process take?
If it’s a problem with processing a bill or a claim, ask your medical provider to fix it with your insurer. If it isn’t a problem with processing a bill or a claim, you’ll need to ask your insurer to change their decision. You can do this by filing an appeal.
Your health insurer must keep covering care during an appeal. Your health insurer can’t change, reduce or stop benefits for ongoing treatment without telling you in advance. If they do, you can ask an independent review organization (IRO) to review that decision (provided under RCW 48.43.535(9)). If you lose your appeal, you may have to pay for the treatment you received.
What to do about bills during your appeal
Tell your medical provider that you plan to appeal your insurer’s decision. Work with them to handle any bills. If a bill is due, you can avoid paying until you win or lose your appeal.
• Ask your provider to not send the bill to collections. They may or may not agree to do so.
• Set up a payment plan and get your provider to agree on how much you owe. This way, you can avoid the bill going to collections.
• Pay the bill and have your health plan pay you back if you win your appeal.
• Try to ask for a lower price if your insurer won’t pay. You have to decide what’s best for your situation. Tips for filing your appeal These tips can help make the appeal process easier for you: How to Appeal a Health Insurance Denial
• Identify your type of insurance coverage. Find out if you have a group, individual or government-sponsored plan. Then, see which law your plan follows.
• For Medicare and other plans like TRICARE or Apple Health for Kids, you will need to follow their appeals processes.
• Find out the deadline for an appeal. Where do you send it? This information is usually in the denial letter. If it’s not, ask your insurer.
• Keep a log of every call, email and letter.
• Gather your medical records. If you don’t have them, ask your medical provider for copies.
Appeal letters should be brief, timely and specific about what you want to happen. It helps to have a supporting letter from your medical provider. Give them a copy of the reason for denial. Keep your original documents. If you have to mail documents, make copies and send them as certified mail.
If you lose an appeal, you can ask for a review. If you lose your appeal and your health plan doesn’t change their decision, you can ask an independent review organization (IRO) to review it. The decision letters from your insurer should explain how to do this. You can also contact your health plan for more information.
An IRO is a company that is separate from your insurer and won’t benefit financially if you win or lose your appeal. The IRO can either agree with or change your insurer’s decision. Once an IRO reviews your appeal, its decision is final.
You can find cases involving your insurer, diagnosis, treatment, decision or reason for appealing.
You may also want to file a complaint
Appealing is different from filing a complaint. You should file an appeal if you disagree with your insurance company’s coverage or payment decision. You should file a complaint if you think an insurer or agent has violated the law or treated you or your claim unfairly. Learn about the complaint process.
You can do both at the same time without them affecting each other.
If you’re not sure how to resolve your issue, you may want to try both. Types of policies that aren’t considered health plans If you have any of the policies listed below, contact your insurance company to learn what appeal process might be available to you, since these polices are not considered health plans by Washington state law:
• Accident-only coverage
• Coverage provided from an auto or homeowner personal injury claim
• Critical illness coverage (a policy for serious illness, like cancer)
• Dental-only and vision-only coverage
• Disability-income insurance
• Employer-sponsored selffunded health plans
• Fixed-payment indemnity or minimized insurance
• Limited health care services
• Long-term care insurance
• Medicare supplemental coverage
• Short-term limited-purpose insurance (i.e., student coverage)
• Workers’ compensation coverage.