Sonya Sellmeyer

By Sonya Sellmeyer, Consumer Advocacy Officer for the Iowa Insurance Division

(Des Moines, Iowa) – According to the Kaiser Family Foundation in 2021, only 1% of all denied health insurance claims were appealed to their health insurance plan.  If you believe the healthcare services you received should have been covered under your health plan, you have a right to an appeal. An explanation of benefits (EOB) is issued by the health plan as a summary of the benefits payment towards a claim and is not a bill.  If a claim is denied, a code explains the reason for the denial.  A claim may be denied for an error, lack of information, out-of-network provider, no prior approval for a service or procedure, or the health plan does not provide the benefit.  If you disagree with the health plan’s determination, review the EOB for the appeal rights information.

There are two types of appeal rights.  An internal appeal is a request to the health plan to review their original decision.  You have 180 days after the EOB to file an internal appeal.  For further guidance on filing an appeal with your health plan, call the customer service number on your insurance card.  The health plan may require a completed appeal form, or letter with supporting information.  If the denial is based on the lack of a medical reason, the healthcare provider may be able to assist by writing a letter or providing additional health information to support the claim. The health plan must render a decision on the appeal within 30 days.  If a delay in receiving medical care could jeopardize the individual’s life, health, or the ability to regain maximum function, you or your provider may be able to request an expedited internal appeal with the health plan.

The second type of appeal is an external review, or the opportunity for an independent review of an adverse determination. You may be eligible for an external review after all internal appeals have been exhausted, and the denial is based on medical necessity, appropriateness, health care setting, level of care, or the effectiveness of the health care service of treatment. There may also be a right to external review if the claim was denied as “investigational or experimental.”  An external review must be filed with the Iowa Insurance Division within 4 months of the date of receipt of the final adverse claim determination notice.  The decision of the independent review organization is binding upon the health plan. Should you disagree with the independent review organization, you have a right to a judicial review in Iowa District Court within 15 business days of the issuance of the decision by the independent review organization.

Always contact your health plan to ensure a provider is in-network, services are covered, and to obtain preauthorizations, including those for dental services, as required by the policy.  Taking these steps will ensure health care services are paid for by the health plan according to the policy.