What kind of denial did you receive?
Chances are you received a denial from your health insurance company for one of these reasons:
- Your health insurance company
- Refused to pay for medical services or care you already received.
- Denied approval for treatment or medical services you are currently receiving or for treatment your doctor thinks you need.
- If you have been denied for an urgent medical need, you may qualify for a quicker or "expedited" appeal.
If you were denied for another reason, call us at 1-888-877-4894 (toll-free) to see if your situation qualifies for an appeal.
Is your medical situation urgent?
If you have received a denial for a pre-service and your doctor believes your situation is urgent, your health insurance company will review your appeal faster than if it's not an urgent medical situation. This is called an "expedited" appeal. These could be handled by the insurance company or sent for an external review by an Independent Review Organization (IRO). IROs are discussed in detail later in this guide.
You can file an expedited appeal if you:
- Are currently receiving or you were prescribed to receive medical services or treatment; and
- Have a situation that is described as "urgent" by your doctor. Urgent means
your doctor believes a delay in getting these services:
- Could seriously jeopardize your life or overall health, or your ability to regain maximum function.
You cannot file an expedited appeal if you:
- Already received the services or treatment and your health insurance company denied the claim, or
- Your situation is not urgent.
Who decides if your situation is urgent?
Your doctor or medical provider will decide if your situation is urgent.
How do you file an urgent or expedited appeal?
You or someone you have authorized to speak for you can call your health insurance company to file an appeal. You may file an urgent or expedited appeal verbally or in writing. Your health plan may respond with a verbal decision but must put that decision in writing within 72 hours of receiving your request. If your appeal qualifies for review independent review organization, your insurer may not require that you complete an expedited internal appeal before beginning an expedited independent review.
If you need to file an urgent or expedited appeal, we suggest you or someone or your behalf (including your medical provider) immediately call your health insurance company.