Usually, the state will dictate which type of filing you have and whether it is a plausible case to file.
Almost every state has passed a law that allows the patient to get a review of their decision.
There are many states that are starting to extend that law to allow patients to file an appeal or a grievance based on the decision or outcome of their claim when they think that they are wrongfully denied coverage.
Not all medical insurance plans are subject to the grievance and appeals process.
Additionally, not all states have a process that patients can embark upon to get the reviews and re-evaluation that they deserve.
You need to understand your state's laws regarding this issue and carefully read through the terms and conditions of any medical insurance plan that you are considering to see if this option is extended to you in your state of residence or not.
Some insurance companies only offer grievance or appeals filing in specific states, even when they offer coverage nationwide.
An appeal allows you to file a claim stating that you want your determination reconsidered.
This is the most common type of claim that is filed on a health insurance claims decision.
A grievance, on the other hand, is a claim that you file that states your problems with anything other than the payment or health insurance services.
If you think a claim was wrongfully denied, you need to file an appeal.
If you were approved coverage but your quality of care was poor for a certain event, you need to file a grievance to resolve that issue.
Grievances and appeals must be filed within 60 calendar days of the services provided or the decision being made.
In certain situations, there can be extensions on this process if you have a good cause.
This typically requires you to write to the health insurance company and let them know why you did not file within the 60-day window and why you deserve to file now.
Things aren't always going to be perfect when it comes to health insurance, and understanding the grievance and appeals process will give you more control over your care and help ensure that you get the coverage that you deserve.
If you need assistance in locating particular coverages at a pre-determined price, we can help you save up to 50% on your health insurance.