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Louisiana Individual Health Insurance Appeal Information

Do I Have Appeal Rights Under My Individual Health Plan?

Yes. When your health plan denies a service because they feel it is not medically necessary, you have a right to appeal the decision with your health plan. The appeals process involves a two-level internal appeal and an external or independent appeal. If a delay in the process will seriously jeopardize your life, health or ability to regain maximum function, an expedited appeal is available. The appeals process is conducted as follows:

• FIRST LEVEL INTERNAL APPEAL - This appeal is requested by the covered person within 60 days of receiving the adverse determination. The Medical Necessity Review Organization (MNRO) has 30 working days following the request for appeal to notify in writing both the covered person and the provider of their decision. MNROs are licensed entities that determine the medical necessity of health care services.
• SECOND LEVEL INTERNAL APPEAL - If the first-level appeal decision upholds the denial, the covered person can request a second-level appeal within 30 days of receiving the first-level appeal decision. The review panel must hold a review meeting within 45 working days of receiving the request for the second-level review. The MNRO has five days following the completion of the review meeting to issue a written decision to the covered person.
• EXTERNAL REVIEW - If the second level appeal decision upholds the denial, the covered person, with the concurrence of the treating provider, may request an external review within 60 days of receiving the second-level appeal decision. The MNRO must provide any relevant information to the designated Independent Review Organization (IRO) within seven days after receipt of request for external review. The IRO shall provide notice of its recommendation to the MNRO, the covered person and the provider within 30 days after receiving the second-level decision information.
• EXPEDITED INTERNAL APPEAL - An expedited appeal can be requested when a denial involves a situation in which the time frame would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function. In such a case, the MNRO must make a decision and notify the covered person and/or provider as expeditiously as possible, but no more than 72 hours after the appeal is commenced.
• EXPEDITED EXTERNAL REVIEW - After receiving an adverse determination involving an emergency medical condition, the covered person's health care provider may request an expedited external review. Within 72 hours of receiving appropriate medical information, the Independent Review Organization (IRO) shall make a decision to uphold or reverse the denial and notify the covered person, the Medical Necessity Review Organization (MNRO) and the treating provider of the decision.

When Does Medical Necessity Review Organization (MNRO) Apply?

You are afforded these appeal rights if you are insured through a fully insured health plan that subjects benefit eligibility to medical necessity requirements. A fully insured health plan is one that is "insured" through a licensed insurance company. Self-funded, employer-sponsored health plans are exempt from the MNRO appeal rules under the federal labor law (ERISA).

The law does not apply to health plans provided by the federal government (including Federal Employee Programs, Medicare and Medicare+Choice), nor does it apply to plans providing only "excepted benefits"(Limited benefit health plans providing coverage only for such conditions as cancer, dental, disability, accidental injuries).