Reviewing Claim Decisions—Internal Appeals and External Review 

This page features information on the following topics regarding reviewing claim decisions:

  • Overview 
  • When a Claim is Denied 
  • Internal Appeals 
  • External Review 
  • Steps for Appealing Health Plan Decisions 
  • Additional Information  

Overview

Under Health Care Reform, health plans must comply with certain procedures regarding decisions to deny payment for treatment or services. When a claim is denied, an individual may request that the health insurance plan reconsider its decision—this review is called an "internal appeal." If the plan still denies payment after considering the appeal, the law permits the individual to have an outside third party decide whether to uphold or overturn the plan's decision—this is referred to as an "external review."

Note: The internal appeals and external review requirements do not apply to grandfathered health plans.

 


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