While navigating a managed care denial is never easy, there are some resources available which can help. Katherine Chewl, a Colorado Springs personal injury lawyer, has put together a guide for you to review should you ever be denied by your managed care plan.
1. By Law, every health care service plan must have a procedure in place for receiving and handling enrollee appeals and grievances. In most cases the plan has 60 days to respond to the situation, but in urgent situations this drops to five days.
2. When a patient feels that a requested service was denied inappropriately, the first thing he should do is read the Evidence of Coverage booklet which plans are required to provide to each enrollee. If the patient cannot find or never received one, they should be available from the employer, or by calling the health plan.
3. The Evidence of Coverage booklet is required to describe the steps to take to initiate an appeal. While the appeal must come from the patient or responsible party, the physician or his staff can assist in preparing the appeal, by providing information concerning the treatment request.
4. Under Business and Professions Code sec. 2056, it is illegal for a plan to retaliate against a physician who acts as a patient advocate in such circumstances.
5. The patient should be prepared to comply with any reasonable requirements contained in the appeal procedure, and to provide any information the plan requests, including record releases.
6. If the health plan is unresponsive to the appeal, does not meet legal time limits, or does not offer a resolution satisfactory to the patient, he can request assistance from the Department of Corporations, which regulates managed health care service plans. The department has a toll-free telephone line for patients to call for help. If the problem is within the jurisdiction of the department, they will send the patient a form called Request for Assistance. It is important for the patient to know that the Department of Corporations cannot intervene until the patient has gone through the appeal or grievance process set forth in the plan’s Evidence of Coverage booklet. If the life or health of the patient would be jeopardized by delay, the department can take expedited action even if there has been no appeal directly to the plan.
7. Some plans require enrollees to submit to binding arbitration of grievances. It is not necessary for the patient to complete that process before filing a Request for Assistance with the Department of Corporations.
8. The Department of Corporation’s toll-free patient assistance line is: 1-800-400-0815
- Inquire about who handles grievances–the HMO or the medical group with which it contracts.
- Ask whether you can appear in person to make your case and whether you can bring a lawyer, friend or doctor with you.
- Adhere to deadlines and insist that your plan do so.
- Insist that claim reviewers be expert and neutral.
- Know the basis of your claim, and ask for citations from the medical literature. If the plan excludes a new treatment, ask whether coverage can be updated.