What help, information & resources can you suggest to help me file an

appeal or grievance with an Insurance Company?

The process of appeals & grievances gets very technical, legal, etc.  I won’t even attempt to summarize it here.  Please follow the links below, guides & summaries to the right,  check your policy – evidence of coverage and check the law.

Medical Procedures?

Was your procedure Medically  Necessary?

Independent Medical Review

Blue Cross Clinical UM (Utilization Management) Guidelines,

Did you use the Correct MD or hospital – Provider List and

Did you Review the procedures in your actual policy, evidence of coverage?

Here’s a sample Speciment EOC Evidence of Coverage – Platinum Plan Page 151

Reasons why the Claim might be denied

Did you tell the truth on your application?
How does the Insurance Company know, if the application wasn’t filled out correctly?
Here’s where they write to your MD, before a claim is even turned in.

How about doing a pros & cons spreadsheet – Ben Franklin method?  It’s important to know the other sides point of view and potential arguments & evidence. 

Billing Codes – Satire or how it really works?

Was the policy in force?  Lapse non pay?  

Insurance Company & Regulatory Agency Grievance Procedures & Forms

Check your EOC – Evidence of Coverage for procedures & where to get forms.

Kaiser, & Blue Shield Grievance Forms


Blue Cross Grievance Procedures


Blue Shield – General Info.  Appeals & Grievances  PO Box 629007  El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585

CA Department of Insurance  

IMR – Independent Medical Review  



#Appeal Guide 
DOI Washington State

how to appeal health care insurance decesion


Navigating the Appeals Process -

Patient Advocate Foundation 

Navigating the Appeals Process


Kantor & Kantor Attorneys

Right to Appeal - if claim denied

You Tube Videos


CA #SmallClaims Court Guide 56 Pages
Gathering the documents you need
CA Small Claims Court Guide


Department of Consumer Affairs - Mediation Request ONLINE

mediation request

How Mediation Works & Paper Mediation Request Form


Appeals?  Grievances?

Check the FULL policy, EOC - Evidence of Coverage here's a specimen and see what the rules are on cancellation and notice.

Then if you do decide to do an appeal, (page 151 in specimen policy) or view our webpage  on appeals, you'll  know what to argue about.

Consumer Links & Resources

How to gather documents to prove your case – Small Claims Manual

Prove you never got a letter?

How to tell your story, timeline and background – actual attorney brief to the court.

How to create a TIMELINE in Word, Excel, PowerPoint

Health Net faces suit over refusal to cover treatments LA Times 9.13.2012

Appeal Guide – Washington State Department of Insurance 62 pages pdf

Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$

Find an Attorney

Health Consumer Alliance HCA
Part of Department of Managed Health Care

What is HCA?


Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –   CA Healthline 5.3.2016

WOW!!! 2.8 Million June 2019 CA Managed Health Care * Insure Me Kevin.com  * 

Dealing with Customer Service Issues

  • First and foremost, be polite. These are crazy days as well for service reps, nearly all of whom aren’t to blame for their companies’ penny-pinching practices. A little civility goes a long way.
  • Don’t be shy about escalating. Front-line service reps are frequently not given the power to resolve matters on their own and will often give an unsatisfactory response. Ask to speak with a supervisor.
  • If that doesn’t work, write to the company’s chief executive or president, detailing the nature of the problem and providing as much documentation as possible. Most big companies have special dispute-resolution departments at senior levels.
  • Be persistent. If it becomes clear that you’re not going away, some companies will finally throw in the towel and offer the response you’re seeking. Squeaky wheels and all that. LA Times 8.8.2020 *

Milliman Waste Study

The U.S. healthcare system wastes close to three-quarters of a trillion dollars a year—and the implications are not just financial. Many of the tests, treatments, and procedures that comprise healthcare waste can expose patients to undue physical, emotional, or financial harm.  http://www.milliman.com/waste

Top 10 Wasteful Services

10 wasteful procedures health


SNAFU – Situation Normal – All Fouled Up
Wikipedia – Including Videos


Specimen EOC Evidence of Coverage – Appeals – Grievances

Steve - when he's not updating the website outside of Open Enrollment
Steve - when he's not updating the website outside of Open Enrollment

1989 Maytag Repairman Christmas Commercial
Maytag Commercial

Technical Links – Appeals & Grievances

Page 19 Section §2719 of Health Care Reform -Appeals Process

45 CFR Part 147    Interim Final Rules for Group Health Plans and Health Insurance Issuers – Appeals

§ 147.136 — Internal claims and appeals and external review processes.

7/26/2011 – Final Rules – EBSA – Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction [PDF]

More Final Rules for EBSA

§10123.13. (a) Every insurer…shall reimburse claims …, whether in state or out of state, … as soon as practical, but no later than 30 working days after receipt…

(b) If an uncontested claim is not reimbursed … within 30 working days…interest shall accrue and shall be payable at the rate of 10 percent per annum …

Search & Find CPT Current Procedural Terminology codes and their relative values at CPT Code/Value Search – Medicare Billing Codes This is a free site for patients and consumers.

See also Medical Necessity

California Insurance Code  §790.03 (h) Knowingly committing or performing with such frequency as to indicate a general business practice any of the following unfair claims settlement practices:   Calif. Code of Regulations TITLE 10. CHAPTER 5 ADOPT SUBCHAPTER 7.5 with new 2004 amendments on CA Department of Insurance Site


Blue Cross Summary 6/2011 on how Health Care Reform mandates will be complied with

Blue Cross Anthem Summary 10/22/2010

Anthem Blue Cross Fact Sheet

22 comments on “Appeal & Grievances?

  1. I have a dental claim that was denied as the Insurance Company says I didn’t have 12 months of coverage as mandated in the policy.

    A 12-month waiting period applies to all Major Services Page 1 of EOC

    My first appeal was denied as the Appeals Review said:

    You have requested that xxx Insurance Company waves the waiting period and reprocess the claims referenced below to allow benefit coverage. We are unable to approve your request.

    During the research of your concerns it was determined that the waiting period has not been satisfied. As stated in your plan’s Evidence of Coverage (EOC) there is a 12-month waiting period before xxx Insurance will pay for major services.

    I want to file another appeal, as the Insurance Company should have it in their records that I’ve had continuous coverage since 2014. The appeals court should find in my favor as the Insurance Company should just pay me, as their records should show that!

    • I don’t think so. The Insurance Company has clearly stated in unequivocal terms that you had a lapse in coverage from 9.30.2019 to 8.1.2020!

      Sure, their records are wrong as you have cancelled checks and I have my commision statements. If you’re going to take this to Appeals, Complaints with Department of Managed Health Care or Small Claims Court, the burden of proof is on you.

      Please review the Appeals Guides above.

      Here’s some excerpts:

      It is important to remember that you do have rights which are described in your insurance policy handbook.

      A health insurance policy is a contract between you, the policy holder, and the insurance company. A denial is a “contract dispute,” and your appeal must be based both on the reason for the denial and provisions in your insurance policy, contract

      Your health insurance plan must notify you in writing of the reason they did not authorize a specific request or denied payment of a service as well as how to appeal their decision

      One of the most important elements of your appeal packet is a clear, concise letter that addresses very specifically the reason of the denial, and incorporates the terms of your policy (or plan language). Patient Advocate.org

      Gathering the Documents You Need

      Prepare for the hearing by gathering any evidence that will help the judge understand the case. Your evidence may include any written contract, receipt, letters, written estimates, repair orders, photographs, canceled checks, account books, advertisements, warranties, service contracts, or other documents. Like your Insurance Brokers Commission Statements. Small Claims Guide

      Please also review these other pages on our website:

      Read the policy, denial letters and other correspondence like where the Insurance Company said that your coverage was lapsed three times and then when you think you understand it, read it again.

      Our webpage on the important of reading the EOC Evidence of Coverage

      Court case stating a policyholder must read their policy.

      Insurance Companies give the wrong answer and then tell the Department of Insurance that an application was never sent in, when they told the agent it would be denied and not sent in

      I’m not practising law or giving legal advice. I’m just showing you research.

      We are not interested in what someone is alleged to have told someone else over the phone

      Don’t get caught off guard at the appeals hearing or small claims court, make sure you have the evidence that the Insurance Company will show to defend their denial of your claim

      • Nah, Steve,

        You’re wrong. I didn’t have to do all the work you said. Blue Shield is paying my claim!

        we have approved your request for payment of claims on September 7, 2020 and September 14, 2020, for $737.00 per claim

        • Sorry, no.

          Please read the entire letter:

          It is important to understand that this decision has been made on an exception basis and, in making this decision, Blue Shield does not waive any of its rights to enforce the provisions of the enrollee’s health plan. Your dental plan requires that you have continuous coverage for 12 months prior to any major dental services are covered. You had two months of coverage from August 1, 2020 through September 30, 2020

          Let’s be clear what exception means:

          The definition of an exception is something that is outside of the rules or outside of the normal expectations.

          An example of an exception is when you are normally supposed to be home by midnight but your parents let you stay out until 1 AM, just for one night. https://www.yourdictionary.com/exception

          There will be no exceptions to this rule. https://www.merriam-webster.com/dictionary/exception

          I ask that you grant an exception in this case

          I understand my current policy is not obligated to pay for this, but I would like to request an

          Health Insurance Appeals and Exception Requests https://www.insurance.wa.gov/sites/default/files/documents/appeals-guide_0.pdf

          Thus, if you have any more claims for major work, it WILL NOT be paid!

  2. I’m having a problem finding a lab that’s approved by my Insurance Company. It’s not clear if the lab in the same medical group IPA where my doctor PCP is. I’m waiting to hear back.

    What if my illness gets worse?

  3. My Medicare Advantage plan, with United Health Care denied coverage for a home health care nurse who came to our house two or three days a week for almost four months.

    I was being treated by Wound Care at Mission Hospital in Asheville, NC. Because I live 75 miles away from them, the doctors authorized a home health nurse and had me come in one day each week and later every other week.

    It was a great service since my husband is 88 and cannot drive the 150 mile round trip and my injury was to my right ankle so I was not supposed to be driving long distances.

    I have read that Medicare Advantage plans often deny this coverage although Medicare provides it.

    Any advice for appealing this???

    • Well let’s research the issue first:

      Surgical dressing services

      Medicare Part B (Medical Insurance) covers medically necessary treatment of a surgical or surgically treated wound.

      Your costs in Original Medicare

      You pay 20% of the Medicare-approved amount for your doctor’s or other health care provider’s services. You pay a fixed Copayment for these services when you get them in a hospital outpatient setting. The Part B deductible applies. You pay nothing for the supplies. https://www.medicare.gov/coverage/surgical-dressing-services

      UHC Bulletin on Wound Care This bulletin is beyond our paygrade… Try the links above.

      Home health aide services: Medicare will pay for part-time or intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting
      skilled care
      . Skilled care includes:

      ■ Skilled nursing care
      ■ Physical therapy
      ■ Speech-language pathology services
      ■ Continuing occupational therapy, if you no longer need any of the above

      Medicare & Home Health Care # 10969

      Medicare Benefit Policy Manual

      Medstarvna.org Wound Care at Home

      Medically Necessary – means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion:
      • In accordance with Generally Accepted Standards of Medical Practice.
      Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness.
      Not mainly for your convenience or that of your doctor or other health care provider.
      • Meet, but do not exceed your medical need, are at least as beneficial as an existing and
      available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively.

      Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

      Home Health Care – Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart in Chapter 4, Section 2.1 under the heading “Home health agency care.” If you need home health care services, our plan will cover these services for you provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements, or full-time nursing care at home.

      Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Our webpage on Medical Necessity

      Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

      Prior Authorization – Approval in advance to get covered services or certain drugs that may or may not be on our drug list (formulary). Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary.

      Page 273

      Send me copies of your actual bills and the denials… It doesn’t look hopeful at this time. Did you follow the appeals procedure for UHC?

  4. I recently had an appt to establish care with a primary physician after 3 yrs without. Various tests were done to assess my current health.

    I was surprised that all were not covered as part of a well woman visit or as preventative screenings.

    A test for Hep C antibodies was covered but the Hep C detection test was not.

    Blood test for lipids and triglycerides was covered but not for other blood chemicals.

    I would suspect both were necessary to provide a health profile.

    The Dr. noticed a bulge of sorts by my naval so she ordered an Abdominal Aortic Aneurysm ultrasound which was not covered.

    The AAA test is covered under the Affordable Care Act and I met four of the risk factors for checking so why was that not considered preventative screening.

    I have filed a grievance but wonder if there’s more info I need to submit from the Doctor as to why the various tests were done.

    • We are talking about what ACA defines as preventative care. Not “establishing” care or “assessing current” health.

      Here’s what is listed as preventative care:


      Blue Shield’s List

      Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92

      If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016 Our webpage on Preventative Care

      Medical Necessity

      Clinical Guidelines

  5. My Insurance Company requires that claims be reported within 90 days. My doctor didn’t meet the deadline, what can I do?

    • Here’s what we found in the Health Net Bronze PPO Enhanced Care:

      NOTICE OF CLAIM: Written notice of claim must be given to Us within 20 days after the occurrence or commencement of any covered loss, or as soon thereafter as reasonably possible

      PROOFS OF LOSS: Written proof of loss must be furnished to Us at P.O. Box 9040, Farmington, MO 636409040, in case of claim for loss for which this Policy provides any periodic payment contingent upon continuing loss, within 90 days after the end of the period of time for which claim is made; in the case of claim for any other loss, written proof of loss must be furnished within 90 days after the date of the loss. Failure to furnish such proof within the time required will not invalidate or reduce any claim if proof is furnished as soon as reasonably possible. Except in the absence of legal capacity, however, We are not required to accept proofs more than one year from the time proof is otherwise required.

      Google Research

      Investigate when claim was filed, etc. etc. with your doctor and insurance company… Nerdwallet


      what if the doctor’s office fails to file the insurance claim?
      What if the doctor files the claim after the normal 90-day insurance claim deadline?
      Do I still owe the doctor for services that would have been covered under insurance but, due to the negligence of the doctor’s office, are now unpaid?

      appeal the coverage denial. In life, the squeaky wheel gets the oil. Start squeaking.

      Obtain a copy of the late claim filed with the insurance company and a copy of the coverage denial letter. The court will be interested in seeing a letter denying an untimely claim submitted by the very doctor who assigned the debt to a bill collector.

      If you do not receive an Explanation of Benefits within 60 days of seeing a doctor, assume something is wrong and contact your insurer and the doctor’s office.

      Sam Turco Law

  6. Steve,

    My check has cleared … they should have it in there records… the last time the same thing… it was received and posted but the account was not updated …. November check has also been sent

    is it so hard to call the carrier and say… “my client is listed as cancelled yet you have received payments…can you tell me why the account is listed as cancelled or what is needed to correct the matter”

    …seems simple and fast…or would you rather wait until I search through cancelled checks to “prove” what is already known?

    • I really don’t like the telephone to deal with anything of a business matter. I much prefer email. When we approach an Insurance Company I like to follow the advice given above and get all our facts and ducks in a row first and be able to clearly express it to the Insurance Company and if need be to show clear concise emails, documents, cancelled checks, whatever is relevant to the Judge or regulatory authorities.

      The reply from the Insurance Company to your email clearly shows the point I’m trying to make.

      You will have to work with Collections to see if you can get your group reinstated. I show that we did not receive your October premiums by 10/31/18 and that is why you were cancelled.

      We have not received your November payment. I have done an audit on your account see attached.

      Collections 800-xxx-2525
      Thank you

  7. I have had many problems sense I was injured

    I have been a victim of medical malpractice

    and my lawyer also had taken advantage of me even with all my notes and complaining to everyone I could think too

    I got ignored and with all my problems

    took long to be able to feel like I can think and healed about all I am going to now

    I suffer and am in desperate need to have answers

    my medical records where compromised leaven me to suffer and

    my lawyer faild me and destroyed all hope for me

    I was double charged and now I can’t work

    waiting for disability



    • 1st off, you probably upset the Insurance Company, using all caps in your correspondence with them. Net Manners.com

      2nd I had to read your email several times and do major edits before I could understand your question.

      3rd – I don’t know what kind of a policy you are talking about.

      I will assume it’s individual health insurance. In our speciment policy page 22 it says that the agreement is monthly. Thus, when you cancel on March 2nd, you are covered for the rest of March and the policy can cancel the last day of March, NOT March 2nd.

      See also the explanation of Monthly premiums on page 32.

      See page 34 on the effective date of termination, which clearly says termination is the last day of the billing period that your termination was received.

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