As an employee covered under a medical benefit plan, you are entitled to certain rights and benefits. One of those benefits is the appeals process. If your requested service is denied, you have the right to appeal that decision and, with some persistence, potentially receive the service you need. However, many people are not aware of this process, or they may not know how to navigate it effectively. In this blog, we’ll discuss how you can utilize your appeal rights when your service is denied.
The first step in the appeals process is to review your Explanation of Benefits (EOB). This document should provide information on the appeals process, including the deadline for filing your appeal. Once you have reviewed your EOB, the next step is to contact customer service. Your insurance provider should have a dedicated appeals department, and they can help you start the process. Make sure to have your EOB and any other relevant documentation handy when you make this call.
The Level 1 appeal is where the member or provider must provide additional information to support the service request. This may include preauthorization, medical necessity, or other documentation that shows why the service is needed. It’s important to be as thorough as possible and provide all necessary information. Keep in mind that the appeals department has a lot of requests to process, so being proactive and organized can help expedite your appeal.
If your Level 1 appeal is denied, you may be able to file a Level 2 appeal. This usually involves a review by an independent body or third-party administrator. Again, make sure you have all necessary documentation and be prepared to provide additional information if needed. Be aware that this process may take longer than the Level 1 appeal, so be patient.
In some cases, it may be necessary to file a Level 3 appeal. This usually involves an administrative hearing or a review by a state or federal agency. This is the most complex and time-consuming level of the appeals process, but it may be necessary if your Level 2 appeal is denied. It’s important to have legal representation if you decide to go this route.
The appeals process can be complicated, but it’s an important right for those covered under a medical benefit plan. If your requested service is denied, don’t give up. Review your EOB, contact customer service, and be prepared to provide all necessary documentation. With persistence and patience, you may be able to successfully appeal the decision and receive the service you need.