Health insurance overview
Denied claims/appeals
Every health insurance company has an appeal procedure defined in its insurance policy. You can appeal an insurance company's decision to deny a claim or a decision to pay less than the amount billed.
You have the right to:
- Receive an explanation of your insurance company's appeal procedures.
- Get help writing and filing an appeal.
- Receive an easy-to-understand written decision for each appeal.
- Appear before a review committee or select a representative to appear.
- File a complaint with the Oregon Insurance Division: www.insurance.oregon.gov or 1-888-877- 4894.
Complaint and Appeals Process
- Your insurance company must acknowledge non-emergency complaints and appeals within seven days.
- Your insurance company must make a decision and respond within 30 days.
- If your insurance company needs more time, it must notify you of the reason and send a decision within 15 additional days. No further extension is allowed.
- Your insurance company must have a process for responding to emergency complaints more quickly. This is called "Expedited Review."
- If your insurance company rejects your first appeal and your plan is through an employer, you may have the right to a second appeal.
- Your insurance company has seven days to acknowledge each appeal and 30 days to respond.
- If your insurance company rejects all appeals, you have the right to an independent external
review for one or more of the following:
- Whether a course or plan of treatment is medically necessary.
- Whether a course or plan of treatment is experimental or investigational.
- Whether a course of treatment is for purposes of continuity of care.
- Other "adverse benefit determination," such as the insurance company rescinded your coverage or ended your enrollment in the plan.
For more information on external reviews, visit the following link:
http://www.cbs.state.or.us/external/ins/consumer/exreview/external_review_info.html
