A plan is not governed by ERISA if it is an individual or family plan, one bought directly from an insurance company for an individual or bought through a state insurance marketplace exchange, or a group employment health plan purchased for a state or municipal employee or employee of a religious organization.
If your physician ordered a specific test or treatment for your medical condition and you received a denial letter from your insurance company, you are probably wondering what options you have. An experienced attorney can help you understand and navigate the Los Angeles Medical necessity denial appeals process for non-ERISA policies so that you can get the coverage you need.
What is a Medical Necessity Denial?
At its core, a denial is simply a contract dispute. Someone believed their insurance would cover a certain test or treatment but the carrier denied they had a contractual obligation to do so. This makes the appeals process two-pronged. First, it should be based on the reason they are denying the coverage. Second, it should also cover the provisions in the insurance policy.
A Policyholder’s Right to Appeal
For non-ERISA policies, the policyholder has the right to appeal their health insurance plan decisions under the Affordable Care Act (ACA) and California law. However, they must follow the process set by the insurance carrier for appeals. In some plans, this can involve multiple appeals.
The Los Angeles Medical necessity denial appeals process for non-ERISA policies can be time-consuming and cumbersome. Therefore, many who are denied health insurance coverage turn to the services of a lawyer to help them win their appeals.
Non-ERISA Appeals Process
The Los Angeles Medical necessity denial appeals process for non-ERISA policies begins with the patient receiving a denial letter. In this letter, the insurance carrier must tell them:
- Their reasons for denial
- That the person has a right to an appeal and how to submit one
- The deadline to appeal
- About any Consumer Assistance Programs in the state that help with medical necessity claim denial appeals
Then, the patient or their attorney can request the support of the physician who ordered the test or treatment. A written letter stating the medical reasons the claim should be approved is usually best. They should provide the insurance carrier with treatment notes and medical records, including any test results. It is also recommended that the patient submits current medical literature or peer-reviewed articles that uphold the effectiveness of any claims involving investigational or experimental services.
Finally, a personal narrative can be quite effective in an appeal. The narrative should describe the need for the requested service. It can be written by the patient, their attorney, or another authorized representative. All this information should be mailed certified with delivery receipt to ensure the carrier receives it on time.
Secondary Appeals and External Reviews
If the insurance company still denies the claim, the policyholder has the right to a second appeal. This means their file will be reviewed by a medical director from their insurance company. Other levels of appeals may be necessary if the treatment the patient’s doctor recommends is considered investigational or experimental.
Under Federal Code § 2560.503-1, a person cannot be forced to submit more than two appeals prior to filing a lawsuit against a health insurance carrier. In addition, a carrier cannot charge someone to file an appeal.
Furthermore, the policyholder has the right to an independent external review for a claim. These reviews use the opinions of a board-certified physician in the same specialty as the patient’s physician and an independent third-party reviewer.
Value of a Los Angeles Medical Necessity Denial Appeals Attorney
Your final option is to file a claim in court. Having an experienced attorney can help increase the chances that your appeal will be granted. They can advocate on your behalf to get the coverage you need. A knowledgeable attorney knows how to make the Los Angeles Medical necessity denial appeals process for non-ERISA policies easier and less time-consuming on policyholders. Call today for a free consultation.