Steps In The Appeals Process
Depending on your specific insurance plan, there are typically three levels of insurance appeals. The process requires you to complete each level, before initiating the next and can be resolved at any one of the levels.
If your claim is denied due to a particular service being billed or coded incorrectly, your mental health professional may be able to gather and submit the necessary information on your behalf to resolve the issue without the necessity of a formal appeal.
First Level Appeal or Request for Reconsideration
The goal of the first appeal is to prove that your claim or request for pre-authorization DOES meet the insurance guidelines and that it was incorrectly rejected. You or your mental health professional may contact your insurance company IN WRITING to request reconsideration. Your mental health professional may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer review” in order to challenge the decision which could resolve the issue.
Second Level Appeal
The goal of this appeal is to prove that the request should be accepted within your health plan’s coverage guidelines. Second level appeals are typically reviewed by a medical director of your insurance plan who was not involved in the claim decision.
Independent External Review
External reviews are conducted by an independent, third-party reviewer in collaboration with a professional who is board-certified in the same specialty as the patient’s provider.
NEED HELP IN FILING AN APPEAL? Call Rhode Island’s Health Insurance Consumer Hotline at 401-270-0101.