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.
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
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?
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
REQUEST FOR REVIEW OF CANCELLATION, RECISSION, OR NONRENEWAL OF HEALTH CARE SERVICE PLAN BENEFITS
Consumer Links & Resources
Free Advice.com WHAT IS THE APPEALS AND GRIEVANCE PROCESS LIKE?
How to gather documents to prove your case – Small Claims Manual
How to tell your story, timeline and background – actual attorney brief to the court.
How to create a TIMELINE in Word, Excel, PowerPoint
Appeal Guide – Washington State 62 pages pdf
Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$
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 *
Right to Appeal - if claim denied
- VIDEO There are ways to get money from your health insurance company even after they denied your initial claim. Here’s what to do if your health insurance isn't covering your best interests
Small Claims Court Procedures & Practices – including training for judges
California Small Claims – Court Site – Self Help
Department of Consumer Affairs on Small Claims Court
Legal Aid Society of Orange County, CA
Small Claims Adviser Los Angeles 213.974.9759
Small Claim Court Study Guide for temporary – pro tem judges – highly likely you might have an attorney whose volunteering to be a Judge for the day.
If you have a claim for more than the Small Claims Limit, you can sue, but you waive the amount over the limit.
SNAFU – Situation Normal – All Fouled Up
Wikipedia – Including Videos
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
FAQ’s – Ask us a Question
Technical Links – Appeals & Grievances
45 CFR Part 147 Interim Final Rules for Group Health Plans and Health Insurance Issuers – Appeals
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 …
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
Other Pages in Appeals & Grievances Section
- Covered CA Appeals
- Insurance Application Disclosures – Table of Contents only
- Last Minute Application? When does coverage start?
- Medical Necessity – reasonable and necessary
- Plain Meaning Rule – Read the statute 3 times