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Health care reform: Fighting health insurance claim denials
Under health care reform there are new rules in place for how insurance companies must act if you want to appeal their decision on a claim for medical services.
The new appeals rules apply to all health insurance plans created or purchased after March 23, 2010, and affect each plan as it starts a new "plan year" or "policy year" on or after Sept. 23, 2010, the date that the new provisions began. But how the law specifically affects you may depend on the state you live in and the type of medical plan you have.
Under the new regulations, you have a right to appeal, or to ask your plan to reconsider its decision to deny a service or treatment. If your claim is denied, the insurer must explain to you how you can appeal its decision. If your appeal continues to be denied, you are allowed to appeal to an external independent reviewer who does not work for your health insurer, and the plan must explain to you how to find that independent review.
When you appeal, you must receive the plan's decision within 72 hours for denials of urgent care, 30 days for denials of non-urgent care you have not yet received, and within 60 days for services you have already received. When dealing with urgent care appeals, both the internal and external appeals may take place at the same time. And some plans may have more than one internal review before an external review is allowed.
Non-English speakers have the right to make appeals information in their native language.