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Right to Appeal Coverage Denials

Health reform guarantees consumers the right to appeal when services are denied by a health plan.  After appealing at the health plan, consumers may be able to request an external review of their claim by an independent third party, who will review the denial and issue a decision.

When the Affordable Care Act (ACA) became law in March 2010, Minnesota already had an appeals process in place similar to the process required in the ACA.   If Minnesota consumers believe a specific service should be covered by their health plan, they have the right to appeal directly to the health plan. If the plan denies the appeal, consumers can request an external review through the Minnesota Department of Commerce (if insured by a commercial insurance company) or the Minnesota Department of Health if insured by an HMO

Health reform builds upon Minnesota's existing appeals process by adding new consumer protections including provisions that:

•  Allow consumers in an urgent medical situation to start the external appeals process at the same time as they appeal to the health plan.

•  Allow consumers to start the external appeals process if they do not receive a timely decision on their appeal from their health plan.
 
•  Beginning in 2014, refund the $25 external review fee to the consumer if the health plan denial is overturned by the external review vendor.
 
•  Beginning in 2014, consumers will not pay more than $75 total for external review fees in a calendar year.
 
 
I understand that some states will run their own external review process and other states will have the federal government handle external reviews beginning in 2012. Will Minnesota run its own external review process after January 1, 2012?

Yes. Since Minnesota already had a similar appeals process to the one called for in the Affordable Care Act, Minnesota will continue its process and continue to handle external review requests for Minnesotans. 

What if I don’t agree with my health plan's decision to deny my claim?

Consumers have the right to appeal any decision by health plan to not provide or pay for an item or service (in whole or in part).

What if my health plan denied my treatment before I received it? Do I have to pay for the treatment myself before appealing or can I appeal now?

The opportunity to appeal is available whenever the health plan denies a service request, even if the denial takes place before the service happens.  It is not necessary to receive the service and have the claim denied before an appeal.

I understand that some states will run their own external review process and other states will have the federal government handle external reviews beginning in 2012. Will Minnesota run its own external review process after January 1, 2012?

Yes. Since Minnesota already had a similar appeals process to the one called for in the Affordable Care Act, Minnesota will continue its process and continue to handle external review requests for Minnesotans.

What if I don’t agree with my health plan's decision to deny my claim?

Consumers have the right to appeal any decision by health plan to not provide or pay for an item or service (in whole or in part).

What if my health plan denied my treatment before I received it? Do I have to pay for the treatment myself before appealing or can I appeal now?

The opportunity to appeal is available whenever the health plan denies a service request, even if the denial takes place before the service happens. It is not necessary to receive the service and have the claim denied before an appeal.

Who may file an appeal?

The appeal may be filed by the person covered under the health plan or by a person named to act for them (an authorized representative).

Can I provide additional information about my claim?

Yes, if there is additional information that may be helpful, it should be included with the appeal.

How long does the health plan have to notify me of their decision?

For most appeals, the health plan must send written notice of their decision within 30 days after receipt of a written complaint.

What if care is urgently needed and I cannot wait 30 days?

If the situation meets the definition of urgent under the law, the review will generally be conducted within 72 hours. Generally, an urgent situation is one in which a person's health may be in serious jeopardy or, in the opinion of the patient’s doctor, the patient may experience pain that cannot be adequately controlled while waiting for a decision on the appeal. If a person believes the situation is urgent, he or she may request an expedited appeal and an expedited external review

I appealed with my health plan and they still denied my service, how do I submit a request for external review?

External review requests for health insurance policies that are not HMO or self-insured employer plans should be submitted to the Minnesota Department of Commerce:
Minnesota Department of Commerce External Review Appeal Request Form

External review requests for HMO plans should be submitted to the Minnesota Department of Health: 
Minnesota Department of Health External Review Appeal Request Form

If health coverage is through a self-insured Employer plan, consumers should contact the Employee Benefit Security Administration at 1-866-444-EBSA (3272).

If you are unsure which type of plan is involved and where to submit a request for external review, check the denial letter from the health plan for more information. The denial notice from the health plan should notify the covered person where to send a request for external review.

Who reviews external appeals in Minnesota?

Minnesota's external review vendor is Maximus, an independent company that contracts with the State to review appeals. Maximus, its employees and physicians are impartial, separate from, and have no affiliation with a health plan.

How much does it cost the consumer to get an external review?

The filing fee for the consumer is $25. The rest of the cost is paid by the health plan.

Do I get a refubd of the filing fees if the external review decision is in my favor?

Not at this time but this will change by 2014.

What if a person cannot afford the $25 filing fee for the external review?

If the $25 filing fee would be a financial hardship, the fee may be waived. A letter should be submitted with the request for external review that explains why the filing fee would be a financial hardship. Examples of financial hardship could be family income, unusual or unexpected expenses, recent change in family circumstances or change in employment status, etc.)
 

What if the external review decision is not in my favor?

The external review decision is not binding on consumers. If he or she loses, there is still the option to appeal the decision in court.  If the health plan company loses, it cannot appeal the decision.
 

How do Minnesotans on Medical Assistance or MinnesotaCare go about filing an appeal?

The Minnesota Department of Human Services has published a Notice About Your Rights for people enrolled in a health plan for their Medical Assistance or MinnesotaCare benefits. Notice About Your Rights for people enrolled in a health plan for their Medical Assistance or MinnesotaCare benefits . This notice explains the process of appealing a health plan decision.  The Ombudsman Office for State Managed Care is available at (651) 431-2660 or toll-free at (800) 657-3729.