Preparing to appeal
Who regulates your appeals process?
Generally, state or federal laws and regulations establish your appeal rights and officials from these governments regulate the process. However, some plans are allowed to set their own rules. Here are guidelines as to who to contact to learn more about your appeal rights.
Individual: If you buy an individual insurance policy (meaning you don't get coverage through an employer) directly from a company, the Oregon Insurance Division likely regulates the plan and its appeals process. Contact an advocate: 1-888-877-4894 (toll-free).
Group: If you have group coverage through an employer, ask your plan administrator or your human resources department about the appeals process and who regulates appeals. It could be state or federal agencies or a plan that doesn't follow state or federal requirements and is allowed to establish its own process. You can also call the Insurance Division for help: 1-888-877-4894 (toll-free).
Medicare: If you have Original Medicare (Parts A and B), a Medicare Advantage Plan, or Medicare prescription drug coverage, Medicare is the contact. Call Medicare at 800-633-4227 or visit the Medicare Appeals and Grievances website. You can also contact a state program that counsels people with Medicare, the Senior Health Insurance Benefits Assistance (SHIBA): 800-722-4134 or www.oregonshiba.org.
Medicare Supplement policies (Medigaps): The Oregon Insurance Division regulates Medicare Supplement plans. Call: 1-888-877-4894 (toll-free).
Oregon Health Plan: Contact a caseworker.
Military personnel with Tricare: Call 1-253-572-2888 or 1-253-572-2350 or visit www.tricare.mil/contacts/
What if you have a doctor bill because of a denial?
If you are appealing the denial of services already received, you might get a bill from your doctor. While awaiting your appeal decision, you can:
- Ask the medical office if you can delay paying it until you know the outcome of your appeal. Ask the medical office to not send the bill to collections; or
- Set up a payment plan (to avoid having the bill sent to collections); or
- Pay the bill and get reimbursed if you win your appeal.