Appeal a Denied Health Insurance Claim: Internal Appeal to External Review

Classify the coverage before filing anything
45 min
Which appeal rules apply depends on who actually carries the financial risk, so pin that down before drafting anything. Nearly every plan falls into one of four buckets:
- Employer self-funded (ERISA) — the employer pays claims from its own funds, often with a carrier such as UnitedHealthcare or Anthem only administering them. Federal rules govern, and the state insurance department has no authority over the plan.
- Fully insured — the employer bought a policy from a carrier, so state insurance law applies on top of federal minimums.
- Marketplace or individually purchased — a policy bought directly; these carry the full set of ACA appeal protections.
- Governmental or church plan — exempt from ERISA; the plan document itself defines the appeal process.
Ask HR or the benefits administrator one question: “Are claims paid from the employer’s own funds or under an insurance policy?” Then request the Summary Plan Description (SPD) — or the individual policy — and open its claims-and-appeals section.
- Read both sides of the insurance card and note the administrator, the carrier and any employer or group name.
- Ask HR or the benefits administrator whether claims are paid from employer funds or under an insurance policy.
- Request the Summary Plan Description or policy and locate its claims-and-appeals section.
- Write the classification — plan type and funding arrangement — on the first page of the appeal folder.

0/4 done

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