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100 Most Influential Lawyers in America
– the National Law Journal

The three steps necessary to start an appeal of a health claim

On Behalf of | Jun 15, 2021 | Insurance & HMO Claim Denials

It is incredibly frustrating to have a medical claim denied by your health insurance company. After all, you make monthly payments just to be insured and the treatment you are seeking reimbursement may have been very necessary. Those in California who have had a health insurance claim denied can seek an internal appeal in an effort to have the costs of their treatment reimbursed.

Step 1: a claim was filed

There are three general steps in the progression of the internal appeals process. First, you must have filed a claim. A claim is simply a request for coverage of the costs of treatment. Claims can be filed either by you or your physician.

Step 2: your claim was denied

Second, your health insurance must have denied your claim. A denial must be sent to you in writing. It must be sent within 15 days if you requested prior authorization for treatment, within 30 days for treatment already received or within 72 hours in urgent care scenarios.

Step 3: you file an internal appeal

Third, you will file an internal appeal. To do so, you must complete any forms required by your health insurer. In addition, you will need to submit to your health insurer any additional information that you think will help your case, such as a letter from your physician. Alternatively, the Consumer Assistance Program in California can file an appeal on your behalf.

Your internal appeal must be filed within 180 days starting when you received notification of the denial. If the internal appeal is for treatments not yet received, your appeal must be completed within 30 days. If your have received treatment and had your claim denied, your appeal must be completed within 60 days.

Learn more about denied insurance claims

Having a health care decision denied can be distressing, but there are steps you can take to appeal a denial. This post is for educational purposes only and does not contain legal advice. Our firm’s website about insurance claim denials may be of interest to those who want more information on this topic.