Health insurance denied a claim or care in Illinois: what to do

Ask your doctor to tell the plan the case is urgent and to request an expedited (fast) appeal. If your doctor says it's urgent, the plan must treat it as urgent.

Why: Urgent appeals must be decided within 72 hours, and you can ask for an expedited external review at the same time.

Read the denial notice. Find the reason and denial code, the deadline to appeal, how to appeal, and who handles external review.

Why: The notice must include these. The deadline and the reason decide your next step.

Appeal before the date the cut takes effect, and say you want the treatment to continue during the appeal.

Why: If a plan wants to cut or stop an approved ongoing treatment, it must tell you in advance so you can appeal first, and coverage must continue while the appeal is pending.

If Medicaid or your Medicaid plan is cutting or stopping a service you get now, appeal (or ask for a fair hearing) and ask to keep your services during the appeal, by the deadline on your notice. For a Medicaid plan appeal, federal rules give you until 10 days after the plan sends the notice or the date the change takes effect, whichever is later; some states give more time.

Why: Asking in time generally keeps the service going until the decision. If you lose, the state or plan may try to recover the cost.

Ask your Medicaid plan for an expedited (fast) appeal, and ask your doctor to support it. If you also need a state fair hearing, you can ask for an expedited hearing in the same request.

Why: An expedited plan appeal must be decided within 72 hours (the plan can extend it by up to 14 days in some cases).

Follow the instructions in your Medicare notice for the first appeal level, and call your State Health Insurance Assistance Program (SHIP) for free help (shiphelp.org).

Why: Medicare and Medicare Advantage have their own appeal process with up to 5 levels; each decision letter tells you how to go to the next level.

Ask the plan, in writing, for a free copy of your claim file and any rule or guideline it used. You can also ask for the diagnosis and treatment codes.

Why: These are free, and asking for codes doesn't count as starting your appeal.

File the internal appeal in writing before the deadline (federal rules give at least 180 days from when you received the denial). Include a letter from your doctor explaining why you need the care. Keep copies of everything.

Why: The plan must decide within 72 hours for urgent care, 30 days for care you haven't had yet and 60 days for care you already got.

Find out whether your job-based plan is self-insured: check the plan booklet (summary plan description) or ask HR.

Why: Self-insured plans are generally overseen by the U.S. Department of Labor (EBSA), not your state insurance department, and generally use the federal external review rules.

If you're in a Medicaid managed care plan, appeal to the plan within 60 calendar days of its notice (orally or in writing).

Why: The plan must decide within 30 days, or 72 hours if expedited (it can extend by up to 14 days in some cases). If it says no or misses its deadline, you can ask for a state fair hearing.

If the denial came from your state Medicaid agency itself (not a managed care plan), ask for a state fair hearing before your state's deadline (at most 90 days from the notice; check your notice). You can ask for an expedited hearing in the same request.

Why: Your notice lists the ways your state accepts hearing requests.

Call your state's consumer assistance program or insurance department for free help with the appeal.

Why: Many states have a Consumer Assistance Program that helps people with health insurance problems, including appeals.

Ask for an independent external review before the deadline (at least 4 months under federal rules; your state may allow more). Your final denial letter says where to send it.

Why: The reviewer must decide within 45 days (72 hours if urgent), and the plan must follow the decision. The federal process is free; a state or plan reviewer can charge at most $25.

If the plan still says no or breaks the rules, file a complaint with your state insurance department (insured plans) or the U.S. Department of Labor's EBSA (self-insured job-based plans).

Why: Regulators can look into whether the plan followed the law.

If your job-based plan's final denial stands, the notice must tell you about your right to sue under ERISA. Court deadlines can be short, so get legal advice quickly.

Why: Plans can't require more than two appeal levels before you can sue.

If you lose the Medicaid plan appeal, ask for a state fair hearing within the time your state allows (90 to 120 days from the plan's decision).

Why: At the hearing you can see your case file, bring witnesses and question the evidence.

If you're being billed while you appeal, ask the provider to hold the bill until the appeal is decided. For a surprise out-of-network bill, call the No Surprises Help Desk at 1-800-985-3059.

Why: A denial about surprise-billing protections can also go to external review.

Keep a record: denial letters, explanations of benefits, your appeals, and notes of every call (date, time, name and title, what was said). Send copies, keep originals.

Why: A clear record helps at every level of appeal.