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How To Appeal Managed-Care Decisions
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Business New Haven
6/20/2000
By: BNH
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The state's Health Insurance Appeals Process Public Act 97-99 gives consumers the right under specific circumstances, when they are covered by a managed care plan, to an external appeal for coverages of medical services or supplies denied to them by their managed care organization (MCO). This right became law on January 1, 1998.
Utilization Review
To understand how the external process works, one should understand what is meant by “utilization review.” This is an assessment and decision-making process used to determine the medical necessity of a medical treatment or service. Utilization review may be performed by an MCO or an independent utilization-review company on behalf of the client's MCO.
Medical treatments or services subject to utilization review may include, but are not limited to:
• Hospitalization, including length of hospital stay
• Surgery
• Mental health and substance abuse
• Specialist referrals
• Outpatient services (e.g., physical therapy)
Typically the doctor will contact the MCO or the utilization-review company acting on behalf of the MCO to request authorization for a specific service or treatment. Based on information submitted by the physician, the utilization-review contact will assess the medical necessity of the proposed treatment and authorize or deny payment for the treatment.
Internal Appeal
for a Denied Medical Treatment or Service
Every MCO or utilization-review company acting on behalf of a MCO has appeal procedures.
When you are denied coverage for a requested medical treatment or service, you may appeal the decision to your MCO or to the utilization-review company acting on behalf of the MCO. This appeal is known as the “internal appeal.”
Many plans have more than one level of appeal. Employees should consult their employers or coverage documents to identify the number of internal-appeal level used by the MCO or utilization-review company acting on behalf of the MCO.
Eligibility for
External Appeal
To be eligible for the external appeal process defined by the state's Department of Insurance, you must satisfy the following requirements:
• You must have exhausted the internal appeals procedures of your MCO, or the utilization-review company acting on behalf of the MCO. The MCO or its utilization-review company is required to provide written notification that you have exhausted the internal appeals process.
• You must file for an external appeal within 30 days of receiving written notification that the internal appeals have been exhausted. Once you have received the final denial letter from the MCO or utilization-review company, you have 30 days to submit a request for external appeal - regardless any other Department of Insurance action. Once the 30-day period expires, the insured will not be eligible for external appeal. The Department of Insurance may have a pending investigation concerning the subject's health-care benefits. If so, the investigation should be considered a separate issue.
• The insured must be an enrollee in the managed-care plan at the time the service was requested. A managed-care plan is defined as a product offered by a managed-care organization (MCO) that employs a network of providers and includes utilization review.
* You may use this external-appeal process only to appeal for services or procedures that are covered in the contract. In other words, the appeals process cannot be used to expand your coverage. For example, this process cannot be used to authorize coverage for providers which are not in the health plan's network. Examples of other services not covered in many health plans may include: wigs, eyeglasses and cosmetic surgery.
• The denial of coverage must be based on medical necessity.
• The appeal cannot be for workers compensation claims.
• A health plan cannot be a “self-insured” plan. The employer can tell if its plan is self-insured. The Department of Insurance has no jurisdiction over self-insured plans. Its Consumer Affairs Division (800-203-3447) can direct inquiries to the appropriate agency for assistance.
• A health plan cannot be a Medicaid, Medicare or Medicare Risk program.
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