Ensuring patients and their providers have an opportunity to appeal a coverage decision by a health plan is important to ensure optimal care. In the past, patients were left with few options when insurers denied coverage or restricted treatment. Today, patients have the right to file an appeal, first to the insurance company (“internal appeal”), and if not satisfied with the decision, they are guaranteed the right to appeal decisions to an independent third party (“outside review”).
While the Affordable Care Act vastly improved patient protections and the right to appeal, the appeals process remains challenging, complex and burdensome for patients and their providers. Individuals are required to research, justify and document medical necessity and evidence of effectiveness. In order to ensure patients and providers are able to easily file appeals in a timely manner, health plans should provide easily accessible, up-to-date information about appeals, including standardized documentation and information about decision-making protocols that may impact the care patients receive.