Three levels of appeals are usually available to patients. The individuals that review your appeal at each level will usually have no prior involvement with your case. Expedited or urgent appeals that are usually decided between 24 and 72 hours may also be available if your condition is expected to worsen without the treatment.
- First level appeal: Also known as an informal appeal. The review at this level is usually conducted by a medical director for the insurance company or managed care organization.
- Second level appeal: Also known as a formal appeal. There are usually 3-5 reviewers, one of whom is a licensed physician in the same or similar specialty as the services in dispute. Some plans allow the member and/or a representative to attend the hearing and present the case.
- External appeal: Also known as an independent review. External appeals are conducted by neutral parties.
- If the availability of an external appeal is a right established by state law, then a state agency usually administers the program.
- However, some traditional indemnity plans that are not subject to state managed care laws will allow external appeals. In these cases, the plan usually contracts with qualified reviewers. There may or may not be fees associated with an external appeal.
While you may be concerned about the outcome of your appeal, it may help to know that, on average, almost half of insurance plan denials are overturned after an external review. The following chart summarizes how consumers have fared with external appeals in your area:
| State | Plan denials overturned | Denials modified | Denials reversed by plans** |
| Alaska* | |||
| Arizona | 21% | 6% | |
| California | 40% | NA | |
| Colorado | 48% | 6% | |
| Connecticut | 72% | NA | |
| Delaware* | |||
| District of Columbia | 67% | 0 | |
| Florida | 50% | 2% | |
| Georgia | 63% | NA | |
| Hawaii | 50% | 0 | |
| Illinois | 27% | NA | |
| Indiana | 50% | NA | |
| Iowa | 42% | 3% | |
| Kansas | 45% | NA | |
| Kentucky | 47% | NA | |
| Louisiana* | |||
| Maine | 38% | 8% | 28% |
| Maryland | 67% | 6% | |
| Massachusetts | 33% | 0 | |
| Michigan | 50% | NA | 17% |
| Minnesota | 21% | 11% | |
| Missouri | 52% | 12% | |
| Montana | 40% | NA | |
| New Hampshire | 43% | 10% | |
| New Jersey | 39% | 13% | |
| New Mexico | 50% | NA | |
| New York | 38% | 12% | 19% |
| North Carolina* | |||
| Ohio | 37% | 11% | |
| Oklahoma | 43% | NA | |
| Oregon* | |||
| Pennsylvania | 44% | 0 | |
| Rhode Island | 69% | *** | |
| South Carolina* | |||
| Tennessee | 44% | NA | |
| Texas | 58% | 10% | |
| Utah* | |||
| Vermont | 40% | NA | |
| Virginia | 60% | 0 | |
| Washington* | |||
| West Virginia* | |||
| Wisconsin* | |||
| TOTAL | 45% | 6% |
|---|
Data from 200-2001
Source: Henry J. Kaiser Family Foundation and Georgetown University Institute for Health Care Research and Policy. 2000-2001.
* Recent addition. Caseload data not available. Utah does not track caseload data
** States where health plans reversed themselves after cases accepted for review.
*** Partial reversals are reported as upheld denials.
NA: Not applicable. State does not provide for modified or partial overturn decisions.
Once you know the type of appeal you will be pursuing, and once you have developed a strategy that fits, you may be ready to begin writing your appeal.