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.