Appealing Health Carrier Decisions
Helping your patients/clients appeal a denied service or treatment
The Illinois Department of Insurance is reminding consumers, health care providers, and patient advocates about consumers’ rights for an independent external review when their health insurance carrier denies a claim or request based upon medical necessity (including health care setting, level of care or effectiveness), experimental/investigational, a pre-existing condition, or rescission of the policy.
This law applies to pre-service, concurrent stay and post service adverse determinations. If the situation is urgent (the time frame for a standard appeal or review could seriously jeopardize the life or health of the covered person), then an expedited internal appeal and/or expedited independent external review may be requested. For all other requests, the internal appeals process through insurance carrier must be exhausted prior to requesting an external independent review.
Requests for independent external reviews are filed with the Department of Insurance by fax, on-line or by U.S. mail. An independent review organization (“IRO”) registered with the Department is randomly assigned to the review, which must be conducted by a clinical reviewer who is a physician or other appropriate health care provider with: (1) expertise in the treatment of the covered person’s medical condition that is the subject of the review, (2) knowledge about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar condition of the patient, (3) holds a non-restricted license in the United States, and for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and (4) has no history of disciplinary actions. For standard reviews, the consumer and/or their authorized representative are notified by the Department of the IRO assigned to the review and are invited to submit any documentation applicable to the request. The carrier is required to send all medical records related to the request to the assigned IRO. Standard reviews are generally finalized within 4-6 weeks and the decision is final, but may be appealed through the court system.
Fully insured Illinois policies are subject to the Illinois law and it generally applies to most major medical polices, including those purchased under the Affordable Care Act (ACA). However, the Department’s Office of Consumer Health Insurance assists consumers by trying to ascertain the type of plan involved, applicable appeal procedures and appropriate avenues for the appeal.
For more information regarding independent external reviews in Illinois, contact the Office of Consumer Health Insurance at (877) 850-4740 or visit the Department’s website at http://insurance.illinois.gov/ExternalReview/default.asp.