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
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