Reader question:

What is the difference between external and internal appeals in the health insurance claim process?

Tammy

Excellent question.

Usually they are all a part of the same fabric. When you start an appeal in a health insurance claim after it has been denied, you are going to start it with an internal appeal. This is the first level of escalation in the health insurance claim process. Once that route has been exhausted, you escalate it to the next level, which is the external appeal. When you make an internal appeal, you are asking to be told more about your health insurance claim and the reasons it was denied and you are also going to be requesting that the health insurance company think over its decision to deny your health insurance claim. If you make an external appeal, after the insurer has denied to do this, you are then appealing to the state government.

Why are you even allowed to appeal to the external state government when your health insurance claim is denied? Most states have certain laws set up that protect the insured. That way, the buck does not stop with the health insurance company. Instead there is some accountability, so that if the insurance company denies you and doesn’t seem to have a good reason, you can get a panel of professionals to look over your claim themselves and see if the denial was right.

When the panel looks over your claim it can be called one of two things: a grievance or an appeal. It varies based on the state you’re in and the type of claim. Usually, if these laws are in place in a state, the professionals that look over your health insurance claim are involved in your health plan, but in some states you can get independent and impartial reviewers.

But the state laws don’t cover every health insurance plan. If the company you work for pays for everything in your health plan and you don’t pay, then they don’t have to submit to these laws. If this isn’t the case with you, you can talk with the department of insurance in your state to see if the laws work in your favor.

Cheers,

Fashun Guadarrama.