What is an appeal?

An appeal is a request for a health insurance company (a payor) or the Health Insurance Marketplace to review a decision that denied a payment or benefit. Individuals can file an appeal in cases in which they disagree with a decision made by the payor or Marketplace, or if an insurer either refuses to pay a claim or ends coverage.

Small business owners can also appeal decisions regarding the Small Business Health Options Program (SHOP).

There are two appeal methods:

  • Internal appeal: individuals can ask their insurance company to conduct a full and fair review of its decision. In urgent cases, individuals can also inform insurers that this process must be sped up.
  • External appeal: individuals have a right to take an appeal to an independent third party for review, which means the insurance company no longer has the power to decide whether to pay a claim.

Why are appeals important in healthcare?

Appeals are important in healthcare because they allow individuals to have their insurers reconsider decisions regarding paying a claim or ending coverage, allowing the individual to be an involved member in health insurance coverage decisions. The power to submit an appeal ensures that patients are paying the correct and fair amount for healthcare services.