APPEAL AND GRIEVANCE PROCEDURES

What Can I Do If My Health Plan Won’t Approve Care My Physician Recommends?

You have the right to appeal your HMO’s decision to deny coverage of health care services. Most noncertification decisions occur when the HMO does not have enough information about your case. More than half of all appeals of noncertification decisions are decided in favor of the patient, so be aggressive in pursuing your rights! Involve your physician in the appeal process because your physician can more easily explain the reason why you need the service in question.

When the HMO denies payment for services, the plan must send you a noncertification letter explaining why the requested services or procedures were denied. The notice must include the underlying clinical reasons for the noncertification as well as instructions on how to appeal the HMO’s decision. Ask the HMO to give you a copy of the reasons it used in making the decision. This will provide you with a more complete explanation for why the requested treatment, procedure or admission was denied.

If the HMO denies coverage, you may first want to try to resolve the problem informally. Most HMOs have an informal review process, where you or your physician can call the HMO to see if the problem can be worked out. This process is voluntary. You do not need to seek an informal resolution of the problem before filing a formal appeal, and you can stop the informal process at anytime and file a formal appeal. However, you may be able to resolve the problem more quickly if your physician calls the HMO and explains the need for the requested services.

If you can not resolve the dispute informally, you can file a formal appeal. You can file an appeal on your own behalf. In addition, a physician or another person acting on your behalf can file an appeal. Usually, the appeal must be in writing. Some HMOs have time limits for filing the initial appeal. Your Evidence of Coverage will describe the HMO’s appeal and grievance procedures, including any time limits for filing appeals and where the appeal should be sent. The appeal letter need not be very detailed (See Sample appeal Letter).

All HMOs must offer at least two levels of appeals. A physician who was not involved in the original decision denying your care must hear the first appeal. Normally, the physician has 30 days to decide the appeal but you can request an expedited appeal if your health would be harmed by the 30-day delay. In an expedited appeal, the physician has up to four days to make a decision. You may request that the decision be made immediately if you have a more urgent health care need. If you are still dissatisfied with the HMO’s decision after the first review, you can request a second review, called a second-level grievance hearing. You can request a second-level grievance hearing by submitting a letter much like the one you sent for first-level grievances.

Second-level appeals are more structured. You have a right at this hearing to:

• Attend the hearing in person;
  
• Bring someone else to help you with the hearing, such as a family member or attorney;
  
• Present your own evidence;
  
• Request information from the health plan in advance of the hearing;
  
• Question other people at the hearing.
  

Sample Appeal Letter

[Your Name]
[Your Address]
[Your Phone Number]
[Your Member Number]

[Date]

Appeals Coordinator
[HMO Address]

Dear Appeals Coordinator:

I am writing to appeal _________ [HMO name]’s decision to deny requested health care services. My physician recommended that I obtain the following health care services: ______________ [describe the services that were recommended]. The HMO denied those services on _________[date of denial notice]. I am writing to request a first-level appeal.

Please send me the clinical review criteria that you used to make your decision to deny the requested services. Also, I would like information about the review process.

[Add the following if you need an expedited review]: I am specifically requesting an expedited review. If I do not receive the requested services soon, my health will suffer. _______________ [Explain why your health may suffer if you go through the normal appeals process].

If you have any questions, you can contact me or my physician. My physician’s name is _________ [physician’s name], and ______ [he/she] can be reached at: [telephone number]. Thank you for your prompt attention to this matter.

Sincerely,

___________ [Sign Your Name]

[Note: You can write a similar appeals letter on someone else’s behalf.]

The HMO will convene a hearing panel to listen to second-level grievances. The panel will usually consist of people who are not employees of the HMO or review organization and who were not previously involved in the decision. If the issue involves a clinical decision, then all of the panelists should be providers who have appropriate expertise in your underlying health problem. The review panel has up to 45 days to hold the hearing and up to 15 days thereafter to make a decision. However, you can request an expedited second-level review if your health could be harmed because of any delay.

In most HMOs, you do not have the right to any further reviews after the second level grievance hearing. However, you may still be able to seek help from the Department of Insurance in settling your dispute. The Department of Insurance’s Consumer Services Division answers the public’s complaints or questions about insurance companies. If you think you have a justified complaint, they may intervene on your behalf.

Advocacy Tips

Obtain a copy of the clinical review criteria that the HMO used in denying your request for health care services. These are the guidelines the HMO uses in deciding whether a person with your condition should receive certain health care services or treatments. Show these criteria to your provider. Sometimes your provider will have additional information that shows why your health care needs meet the HMO’s clinical review guidelines.

• As mentioned earlier, more than half of the appeals that members filed in 1998 were decided on behalf of the patient. Part of the reason for this high success rate is that members or their providers furnished additional medical information supporting their request for treatment.
  
  
• It is also important for both you and your provider to keep copies of all correspondence or notes of conversations (with names and dates) you have had with the HMO. For example, if someone in the HMO approved certain services, the HMO may not later deny payment for that care. These notes may come in handy during your appeal.
  
  
• Contact the NC Department of Insurance’s Consumer Services Division if you still have a problem with your HMO after exhausting your internal appeals.
  
  

Can I Sue My Health Plan If I Was Hurt Because They Would Not Cover Care My Physician Recommended?

Most people have limited ability to sue their HMO or other insurance company. This is particularly true if you want to sue the company for the harm caused by its negligence or malpractice in determining the type of care you should receive. You may have more rights if you are seeking reimbursement just for the cost of the services that you thought should be covered.

However, there are some exceptions to this general rule. For example, state employees and Medicaid and Medicare recipients may have the ability to sue their health plan for malpractice. This is a very unsettled area of the law. Currently there are several bills pending in Congress that would give you the right to sue your health plan for malpractice if you are harmed. If you are considering a lawsuit, it is wise to check with an attorney who specializes in this area of the law.

What If I am Unhappy with My HMO?

You have the right to file a grievance any time you are dissatisfied with your HMO’s policies, decisions or actions. For example, you can file a grievance if you are unhappy with the quality of care or the availability of health care services offered by a health plan. You can file a grievance if the HMO or insurance company fails to reimburse you for certain out-of-pocket payments that should have been covered by the plan. However, before filing a formal grievance, you may want to call the health plan or insurance company to see if you can work out the problem informally. You don’t need to call the health plan before filing a grievance, but you may be able to get your problem solved quicker by calling the HMO first.

If you file a formal grievance, you have the right to two levels of review: These are first- and second-level grievance hearings. You, someone acting on your behalf or your physician can file a grievance on your own behalf. The HMO must provide you with information about the grievance process within three business days after receiving notice of the complaint. The person who reviews the grievance may not be the same person who initially handled the matter. If the issue is a clinical one, at least one of the reviewers will be a medical physician with appropriate expertise. The HMO has 30 days to make a decision.

If you are dissatisfied with the HMO’s decision, you can request a second-level grievance hearing. Members have more extensive due-process rights at the second-level grievance review. Specifically, a member can:

• Attend the second-level grievance hearing;
  
• Request and receive all information relevant to the case in order to prepare for the hearing, present his or her case to the review panel;
  
• Submit supporting materials before and at the review meeting;
  
• Ask questions of any member of the review panel; and
  
• Bring another person to help in the review hearing. This person can be a family member, employer or attorney. However, if the member brings an attorney then an attorney may also represent the HMO.
  

The HMO will convene a hearing panel to hear second-level grievances. The panel will usually be comprised of people who are not employees of the HMO or the review organization, who were not previously involved in the decision and who have no financial interest in the outcome of the review. The review panel has up to 45 days to hold the hearing and up to 15 days thereafter to make a decision. This decision is then presented to the HMO. The HMO must provide you with a written notice of the decision, explaining the rationale.

You do not have the right to any further reviews in most HMOs after the second-level grievance hearing. However, you may still be able to seek help from the Department of Insurance in settling your dispute. The Department of Insurance’s Consumer Services Division answers public complaints or questions about insurance companies. The Consumer Services Division may intervene on your behalf if they believe you have a justified complaint.

RETURN TO HOMEPAGE