Appealing a Reimbursement Decision
Suppose your insurer won’t pay for a healthcare service, or pays less than you had expected. You have the right to “appeal,” or ask for your case to be formally reconsidered.
Before you file an appeal, talk to your insurer and find out why payment was denied. It might have been a simple mistake, like a coding error. But, the payment may have been denied for some other reason—for instance, because your insurer did not find the treatment medically necessary. In that case, you can appeal.
There are several ways to get instructions on the appeals process. You can call your plan, visit your insurer’s website or read your plan documents or Explanation of Benefits (EOB). You have more than one chance to get your decision reviewed. In most cases, there are three levels of appeals:
An internal review by your insurer.
A second-level appeal to the insurer if the first is denied. That appeal will be reviewed by people who weren’t involved in the first appeal.
If that appeal is denied, a third-level appeal, to an independent outside organization.
Avoid a claim denial by making sure you have the facts about your coverage. Before getting treatment, ask:
Is it covered? Check your plan documents or call your insurer.
Do you need preauthorization, or your plan’s approval before you get care? If so, make sure you get it before you visit the provider. Keep a record of the approval number and any supporting documents.
Are there any limits? For instance, you may only get 12 physical therapy visits each year. If you need more, claims for those extra visits may be denied.
If a claim is denied:
Talk to your insurer first to make sure the denial was not a simple error.
File your appeal within the plan’s deadline. Make sure your appeal form or letter is complete and includes any required supporting documents. Your doctor may be able to help.
Keep a record of all communications with your plan. That includes any documents and notes on when you called, to whom you spoke and what was said.
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The Affordable Care Act
The Affordable Care Act (ACA) of 2010 makes it easier for many Americans to get health insurance. It also expands the services that health plans need to cover. For many people, the ACA ensures that they can get preventive care for free through their health plan. That may include yearly health exams and cancer screenings. If you need to buy coverage, you’ll be able to use a “health insurance exchange.” You can think of the exchange as a website where you can shop and compare plans.
Under the ACA, all Americans must have “minimum essential coverage” or pay a penalty. That minimum includes mental and emotional health services, emergency services, maternity and newborn care and preventive/wellness services. Your employer’s plan, an individual plan that you buy and public insurance like Medicaid are all minimum essential coverage.
If you can’t afford a health plan, and your employer doesn’t offer one, you may be able to get tax subsidies to help cover the cost. That will depend on your income, family size and other factors.
Most plans require cost sharing: you pay for part of your care, and your insurer covers the rest. Health plans on an exchange are grouped into five kinds of cost sharing: Platinum, Gold, Silver, Bronze and Catastrophic. Platinum and Gold plans require higher premiums than Silver and Bronze plans, but have lower deductibles, coinsurance and copays.
A Catastrophic plan is a special type of plan for people under 30 and those with “hardship exemptions.” Such a plan typically has lower premiums. But, it covers your medical costs only after you’ve used a lot of care.
You can get more information on your rights under the ACA, and the types of plans available, at www.healthcare.gov.
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Protections for New York Consumers: Understanding Your Out-of-Pocket Costs
By law, consumers living in New York State have certain protections when shopping for and using their health insurance. Your insurer must provide up-to-date information about who is in your network. They must explain what they will reimburse for care outside of their network of doctors, hospitals and other providers. They are required to give examples of their reimbursement calculations for common out-of-network services. In these examples, all insurers must use the same standard of “usual and customary cost,” which is FAIR Health’s 80th percentile benchmark charge for a service, so that consumers can easily estimate their out-of-pocket costs for different plans. Check plan documents to see examples and compare one plan to another.
The law also provides protections for high out-of-network bills for emergency services. If you are insured, you are protected from high bills for out-of-network emergency care for health problems that threaten life or in other ways call for immediate attention. (But, if you have a high-deductible plan, there can be bills for in-network services that you are likely to consider “high.”) If you are uninsured, you may submit disputes about bills for emergency services to a dispute resolution process established by state law.
Under New York law, you also are protected from unexpected “surprise” bills for planned care if you inquire in advance to find out if all your providers will be in your plan’s network. A surprise bill typically happens when you get care from an out-of-network doctor working at an in-network facility. In New York State, if you get a surprise bill for planned care from an out-of-network doctor or facility when you tried beforehand to stay in your plan’s network, you have to pay only the amount you would have owed for in-network care.
Suppose you have a life-threatening or degenerative condition, and you need a doctor with a rare specialty, or a hospital that provides special treatment. Your plan’s network may not include that provider. In such cases, the law requires plans to let you access necessary providers and pay for those special services on the same basis that you would pay a network provider. For such services, check with your plan to get permission ahead of time.
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