Guide to appeals and grievances : your rights as a health insurance consumer

              Guide to
APPEALS
AND
GRIEVANCES
YOUR RIGHTS AS A HEALTH
INSURANCE CONSUMER
Jim Long, Insurance Commissioner
North Carolina
Department of Insurance
A Message from
Insurance Commissioner Jim Long
As health care coverage becomes more
complex, it’s easy to become bewildered and
frustrated. In an effort to help you sort
through this confusion, the NC
Department of Insurance has designed this
brochure explaining the mandatory appeal
and grievance processes.
This brochure will not only explain your
rights as a consumer under North Carolina
law, but will also explain how you can
challenge a plan’s decision or resolve complaints.
North Carolina’s appeal and grievance laws apply to all types of full
service health plans, including traditional indemnity, health
maintenance organization (HMO) and preferred provider
organization (PPO) coverage.
In addition to the information contained in this brochure, I
encourage you to take the time to read the information provided
by your health plan when you first enrolled (your certificate of
coverage, insurance policy and member handbook). This
information will contain more details about your plan’s appeal and
grievance procedures.
We encourage you to become familiar with your plan’s appeals and
grievance procedures. When you know your rights, getting the
health care coverage you need is much easier!
If you are having trouble going through the process or have
questions, please feel free to contact the Department’s Consumer
Services Division at 1-800-546-5664.
WHAT IS AN APPEAL?
When you request a health care service, your insurance plan will evaluate
your request through a process known as utilization review (UR). UR is
the formal process by which a health plan monitors the use of health care
services and evaluates the necessity and appropriateness of requested services,
procedures, providers and facilities. If your plan refuses to pay for the
requested service, it will issue a “noncertification.” A noncertification is
the denial, reduction or termination of health care services that do not
meet the plan’s requirements for medical necessity, appropriateness, health
care setting, level of care or effectiveness.
State law allows you to challenge your health plan’s noncertification and
force the plan to formally review its decision. This review process is known
as an “appeal.” An appeal is available anytime a plan issues a noncertification.
The appeal process is voluntary. Keep in mind that it is not considered a
noncertification when your plan refuses to pay for a service that your
certificate of coverage clearly states is not covered. In that case, the right
to appeal does not apply.
WHAT ARE MY RIGHTS WHEN I REQUEST SERVICES FROM MY HEALTH PLAN?
By law, qualified health care professionals must administer your plan’s UR
program under the supervision of a medical doctor. The UR program
must use up-to-date medical review criteria. Before you can be denied
care, your plan must obtain information about your medical condition and
a medical doctor must evaluate the appropriateness of the denial.
HOW LONG MUST I WAIT FOR A DECISION FROM MY HEALTH PLAN?
If you request a coverage decision from your plan before receiving a service
or request to continue a previously approved service, the plan has 3 days to
respond to you and your provider. However, your health plan has 30 days
to notify you of an adverse UR decision on a service that you have already
received.
HOW MUCH INFORMATION MUST MY HEALTH PLAN PROVIDE WHEN IT DENIES A
SERVICE?
When your health plan issues a noncertification, state law requires the plan
to provide the following information to you in writing:
why the plan is denying coverage for the service,
instructions for appealing the plan’s decision, and
instructions for requesting the plan’s medical review criteria.
This information will enable you to better understand the plan’s decision
and can be of assistance if you decide to file an appeal.
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IS A FORMAL APPEAL MY ONLY OPTION?
Some health plans have a voluntary, informal reconsideration program in
addition to the formal appeal process. Your member certificate or insurance
policy will indicate whether your plan has such a program. The
reconsideration procedure provides an opportunity for your doctor and the
plan’s medical director to discuss your medical condition in detail and, if
possible, resolve the issue of coverage without the need for a formal appeal.
Your plan cannot require you to participate in this informal process.
However, pursuing the informal process, when available, may help you
resolve the matter in less time and with less effort.
HOW DO I PURSUE A FORMAL APPEAL?
To begin the appeal process, you, your provider or your representative
must send a written request to the plan. To avoid confusion, your request
should clearly state that you are appealing the plan’s noncertification decision
and specify the health care service in question.
Within 3 business days after receiving your request, your plan must tell you
the name of your appeal coordinator and how to contact him or her. Your
plan must also tell you how to submit a written statement or other material
for consideration. A medical doctor who was not involved in the plan’s
original decision to deny coverage must evaluate your appeal.
Within 30 days of receipt of your appeal request, the plan must send you its
decision in writing. This written notice must include:
the qualifications of persons involved in reviewing your appeal,
a statement of the reviewers’ understanding of the reason for
your appeal,
the plan’s decision,
the reasons for that decision, and
instructions for requesting a second-level review hearing.
WHAT IF MY CONDITION IS VERY SERIOUS AND I CAN’T WAIT 30 DAYS?
If the time required for the standard appeal process could seriously jeopardize
your life, health or ability to regain maximum function, then the health
plan must expedite its review process. Your health plan is allowed to request
medical documentation justifying your request for an expedited appeal.
Expedited appeals are reviewed in consultation with a medical doctor.
The plan must let you know its expedited review decision within 4 days.
Expedited review is not available for appeals related to services you have
already received.
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WHAT IF I’M STILL NOT SATISFIED WITH THE PLAN’S DECISION?
If you are not satisfied with the appeal decision, you, your provider or your
representative can request a second-level review hearing from your plan.
Within 10 business days after receiving your written request, the plan must
assign a hearing coordinator to you and tell you how to contact him or her.
You have the right to:
• request information about your case from your plan,
• attend the hearing and present information to the review panel,
• submit supporting materials before and at the review hearing,
• ask questions of the panel members, and
• be assisted or represented at the hearing by a person of your
choosing, including an attorney.
Although you are not required to attend the hearing, doing so will allow
you to speak directly to the panel members reviewing your case and to
respond to their questions. The plan cannot be represented at the hearing
by an attorney unless you are.
Your review hearing must take place within 45 days of the plan’s receipt of
your written request for second level review. The plan must give you at
least 15 days’ prior notice of the hearing date, time and location.
WHO MAY SERVE ON THE PANEL HEARING MY CASE?
Panel members must be health care providers with clinical expertise related
to the service you requested. They may not be employees of your health
plan* or have any financial interest in the outcome of the hearing. Providers
previously involved in any matter related to your case may not serve on the
panel. At least one panel member must be a “clinical peer” of your provider,
that is, a health care professional licensed in the same or similar specialty
as your provider. In order to qualify as a clinical peer, a provider must also
routinely provide the health care service you’ve requested.
* North Carolina law currently permits a health plan employee to serve on the
second-level review panel if the plan used a clinical peer to review the first-level
appeal of the case.
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HOW LONG WILL I WAIT FOR A DECISION?
Your plan must issue a written decision to you within 7 business days after
the hearing. The written decision must include:
• the qualifications of review panel members,
• a statement of the panel’s understanding of the nature
of your complaint,
• the panel’s recommendation to the plan,
• the rationale behind the panel’s recommendation
• a description of the documentation considered by the panel, and
• a clear statement of the plan’s final decision.
If the plan’s final decision differs from the panel’s recommendation, the
rationale for the plan’s decision must also be provided.
IS AN EXPEDITED SECOND-LEVEL REVIEW AVAILABLE?
Yes. You may qualify for an expedited second-level review whether or not
your initial appeal was expedited. In the interest of time, the expedited
second-level review may take place via conference call or the exchange of
written information. The expedited review decision must be communicated
to you within 4 days.
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WHAT IS A GRIEVANCE?
In addition to noncertification appeals, your rights under North Carolina
law extend to other complaints against your health plan. Such complaints,
called “grievances,” can relate to any plan decision, policy or action related
to the availability, delivery or quality of health care services; claims payment
or handling; reimbursement for services; or the contractual relationship
between you and the plan.
HOW DO I FILE A GRIEVANCE WITH MY HEALTH PLAN?
If you have a complaint against your health plan, you can file a grievance
by submitting your complaint in writing to the plan. The grievance process
is voluntary.
WHAT HAPPENS NEXT?
Some plans have a “quick review” process designed to resolve complaints
quickly and informally. If your plan does not have such a process or if your
grievance is not resolved as a result of the informal process, you are entitled
to a formal, two-level grievance review. North Carolina law does not require
that your plan provide expedited review of grievances.
Within 3 days of your filing a written grievance, the plan must assign you
a grievance coordinator and tell you how to contact him or her. In addition,
the plan must provide instructions on how to submit written material for
consideration by the grievance review panel.
WHO REVIEWS MY COMPLAINT?
Only plan personnel who were not involved in the matter giving rise to
your complaint may review your grievance. If your complaint involves a
clinical matter, at least one of the panel members must be a medical doctor
with clinical expertise appropriate to the matter under consideration.
WHEN CAN I EXPECT A RESPONSE FROM MY HEALTH PLAN?
Your plan’s written decision must be communicated to you within 30 days
after receiving your grievance. In its decision, the plan must:
• inform you of the professional qualifications of the reviewers,
• provide a statement of the reviewers’ understanding of
your complaint,
• clearly state the reviewers’ decision, including any contractual
or medical basis for the decision,
• describe the evidence used in making the decision, and
• advise you of your right to a second-level review.
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HOW DO I PURSUE A SECOND-LEVEL GRIEVANCE?
Second-level grievance review must be requested in writing after you’ve
received the plan’s first-level decision. Within 10 business days after receiving
your request, the plan must assign a hearing coordinator to you and tell
you how to contact him or her. You have the right to:
• request information relevant to your case from your plan,
• attend the hearing and present information to the review panel,
• submit supporting materials before and at the review hearing,
• ask questions of panel members, and
• be assisted or represented at the hearing by a person of your
choosing, including an attorney.
Although you are not required to attend the hearing, doing so will allow
you to present your case directly to the panel members and to respond to
their questions. The plan cannot be represented at the hearing by an attorney
unless you are.
Your review hearing must take place within 45 days of the plan’s receipt of
your written request for second level review. The plan must give you at
least 15 days’ prior notice of the hearing date, time and location.
WHO CAN SERVE ON THE PANEL HEARING MY GRIEVANCE?
The panel must be comprised of persons who were not previously involved
in any matter giving rise to your grievance, who are not employees of your
health plan and who do not have any financial interest in the outcome of
the review. If the matter under review is clinical in nature, the panel must
consist of medical practitioners with appropriate expertise.
HOW LONG WILL I WAIT FOR A DECISION?
Your plan must issue a written decision to you within 7 business days after
the hearing. The written decision must include:
• the qualifications of review panel members,
• a statement of the panel’s understanding of the nature
of your complaint,
• the panel’s recommendation to the plan,
• the rationale behind the panel’s recommendation,
• a description of the documentation considered by the panel, and
• a clear statement of the plan’s final decision.
If the plan’s final decision differs from the panel’s recommendation, the
rationale for the plan’s decision must also be provided.
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North Carolina Department of Insurance
430 North Salisbury Street
1201 Mail Service Center
Raleigh, NC 27699-1201
1-800-546-5664 • 919-733-2032
7,000 copies of this public document were printed at
a cost of $1,900.58 or $0.272 per copy.
IS AN EXPEDITED SECOND-LEVEL REVIEW AVAILABLE?
North Carolina law does not require your plan to make expedited grievance
hearings available.
WHAT IF I HAVE STILL HAVE QUESTIONS?
The Consumer Services Division of the Department of Insurance is here
to help. Call 1-800-546-5664 for assistance.
The information presented in this booklet describes the appeal and
grievance provisions of North Carolina law. Your health plan may have
certain requirements or policies, such as time limits for filing review
requests or submitting additional information, that may affect your
appeal and grievance rights. For detailed information about your plan’s
requirements, carefully review your Evidence of Coverage or health
insurance policy, and contact your plan with questions.
North Carolina Department of Insurance
Consumer Services Division
1201 Mail Service Center
Raleigh, NC 27699-1201