Appealing Decisions by your Ohio Health Insurance Company

How to appeal a decision by your health plan

You may not always agree with decisions your health plan makes regarding your care. If such a dispute occurs, you can appeal the plan's decision.

My health plan refuses to pay for a treatment I need. What can I do?

Review your policy or benefits booklet for information on filing a complaint and / or an appeal. You can also contact the company's customer service office. Most companies have toll-free telephone numbers.

Ohio health plans have an internal process for appeals. If you are not satisfied with the way your claim was treated, you can request an appeal.

How can I get an appeal started?

The plan's internal appeal process is your first step if you disagree with a decision your insurance company makes. Your policy has specific details on your health plan's review process. You can appeal any decision the insurance company makes.

Contact your plan to begin an appeal. Some carriers will accept a telephone appeal, while others require a written appeal. The carrier must notify you in writing of its final decision within a specific time frame. You must complete the plan's appeals process before you can move to the next step.

What if the plan rejects my appeal?

It depends. Once you've completed the plan's internal appeal process:

• If you have been told the service you requested is not covered under your policy, you can ask the Ohio Department of Insurance to review this decision.
• If the plan denies, reduces or terminates a service or treatment because the plan determines the service or treatment is not medically necessary or experimental / investigative, your case could be eligible for an external review with an independent review organization (IRO).

Does my case qualify for an external review? What is the review process?

Appeals denied through a health plan's internal process generally may qualify for external review with an IRO when:

• The insurance company has determined the service you want is not medically necessary,
• Your provider documents that the service (and all care related to the service) will cost you more than $500 if not covered, and
• You request external review within 60 days of being notified about the internal decision.

The independent review organization conducts each review through a clinical peer...that is, a medical professional who has credentials appropriate to the case. IROs are accredited by the Ohio Department of Insurance and are not affiliated with any insurance company.

The insurance company is required to pay all external review fees. Once the IRO has the needed information, it must make a decision within 30 days. Decisions must be expedited if your health condition requires it.

The IRO decision is binding on the health plan, so if the IRO finds that the service or treatment should be covered, the insurance company must pay for it.

How do I request an external review from an IRO?

Request the review directly from your health plan. See your contract or evidence of benefits for instructions.