Where to start
Appeals generally have three phases:
- Denial of request for service or payment
- Internal appeal to your health plan
- External appeal to an independent reviewer (for certain denials)
To know what appeals process you will follow, you need to answer these questions:
- What kind of insurance do you have?
- Do State of Oregon or federal officials regulate your plan?
- Is your plan a new plan (non-grandfathered) or an old plan (grandfathered)?
- Is your denial a "pre-service" issue, meaning you have not yet received the services, or a "post-service" issue, meaning you have received the services and may be receiving a bill?
- If it's a pre-service issue, is it urgent? Urgent means that your health may suffer if you do not receive the service.
All insurance companies have avenues to resolve issues without having to appeal: When in doubt, ask your health plan to re-evaluate the denial
Click above to display tip
- Your health plan CANNOT drop your coverage or raise your rates because you ask it to reconsider a denial. You are allowed to ask for an appeal - it's your right.
- You do not have to pay for the appeal.
- You can ask to continue to receive services during the appeal but if the denial is not overturned, you will have to pay for those services.