How to appeal denials of care
To make sure that managed-care organizations don’t restrict tests and treatments so that patients are denied life-saving
medical care, 43 states and the District of Columbia have a review process that allows patients to appeal denials of care.
Here’s how it works. You must first take your case to your HMO or PPO. If it rejects your claim, you can appeal to an independent
panel that is sponsored by the state. (People whose employers are self-insured are not eligible to go before the panel. If
you’re not sure about your employer’s status, talk to your human-resources department.)
Follow the proper procedures. To qualify for a hearing, your dispute must usually involve medical necessity; that is, you or your doctor thinks that a
particular treatment is essential for your health. Not every state, however, will allow patients to petition for experimental
treatments, or surgeries like a gastric bypass. In some states, the contested care must cost you a minimum amount, usually
$100 to $500. You have a limited amount of time to file your appeal, which may be as little as 30 days in some states. If
a delay in treatment would jeopardize your life or health, states provide for expedited review, usually within 3 or 4 days.
Don’t skip steps. A 2004 study by Consumers Union’s Center for Consumer Health Choices and the Kaiser Family Foundation found that patients
are too often making mistakes appealing their disputes. For example, patients did not complete the appeal at their managed-care
organization before turning to independent review. That oversight accounted for 18 percent of rejected cases in North Carolina
between 2002 and 2004. (Patients can go back and plead their case with the HMO.)
States also told us that patients frequently did not provide sufficient documentation of their dispute to go forward with
the review. Consumers must show their medical records and proof that the procedure in question is medically necessary and
not experimental.
Learn your state’s rules. To figure out if you are eligible for external review in your state, consult “Consumer Guide to Handling Disputes with Your
Employer or Private Health Plan,” available free from the Center and Kaiser at www.kff.org/consumerguide and www.ConsumersUnion.org/health/hmo-review.
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