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Linda Collins Blogger

Appeals and Complaints: Private Insurance Companies

Posted by Linda Collins | March 29, 2018

The Affordable Care Act provides consumers with significant protections, including the ability to appeal decisions by plans to deny coverage of needed services. The law ensures consumer's rights to appeal health plans decisions or request a reconsideration of a decision to deny payment for a service or treatment.

The first step is to ask the pa​​yer about their appeals process. Many private payers insist the appeal come from the patient or that the patient completes a form authorizing the provider of service to initiate the appeal. Be sure to get the details and complete the required forms.

If you still receive a denial after following the internal complaint process, you may contact your state's Department of Insurance for additional support. The agency can assist with complaints regarding claims, coverage, and denials.

Each state has a Department of Insurance even though it may operate under a different name. Each state has a website for its insurance department Most of the websites allow you to easily file your complaint online. The NAIC Consumer Complaint Map will give you access to each state's insurance department.

From this page, you can file a complaint directly with your state insurance department. Click on your state to be taken to the state's online filing site. Follow the state's process for filing your complaint. If you complete the online complaint form, your complaint will automatically be forwarded directly to the appropriate department for handling.

What does this mean for you?

When you and your patient are experiencing challenges with a particular insurance company, whether it is timeliness of payment or denials of coverage, first you must follow the appeals process outlined by the payer. If you do not receive answers from this path, then contact your state insurance department.

If your patient obtains health insurance through a job, he may want to talk about his concerns with the human resources department. Or you can contact the U.S. Department of Labor's Employee Benefits Advisors for help by calling 866-444-EBSA (3272).

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