If you have submitted a claim to your insurance and it was denied, you are allowed to appeal the denial through an internal process. The first thing that you will want to do is to look closely at your insurance policy to determine exactly what is covered and what isn’t covered. If you were denied coverage or reimbursement and you feel that it was unfair based on your insurance policy, you can file an internal appeal.
If you file the internal appeal and you are still not satisfied with the outcome or if your insurance carrier waives your appeal, there is recourse. The recourse is that you (or an authorized representative for you) can request that the Independent Review Organization, or IRO, review the decision. That would be considered an external review.
What exactly is an external review?
An external review is a review by a person or entity that has absolutely nothing to do with your insurance company or your particular insurance policy. Before you are granted an external review; however, you will need to qualify for that type of review. Subsequently, the IRO will assign you a reviewer at random.
External reviews are carried out by IROs. The IROs must be certified by the Oklahoma Insurance Department, or OID, as well as holding national certification. The criteria for being certified is that the examiner must prove that they are unbiased and that they have a process to guarantee that their examiners are fully qualified and independent.
Which disputes are eligible for examination and which are not?
Some disputes qualify to go through external review and others don’t. The criteria for eligibility are based on medical necessity, health care setting, appropriateness and care level or effectiveness. This includes denials because a treatment is investigational or experimental.
If your claim involves a treatment that is not covered by your insurance. Additionally, if you carry government insurance (such as Medicare, Medicaid, or some other government plan), you won’t meet the eligibility requirements for an external review. When you receive the denial from your insurance, you will also receive information on your rights for appeal. You will also be informed at the same time about asking for an external review.
Once you have filed an internal appeal and it was denied, you can apply for an external review to the OID. You will have four months from the date of the final decision to request the external review. If the result of your external appeal is positive, your insurance company is obligated to abide by the decision.
You have rights and you need to protect them
If you have been unjustly denied based on the claim that you submitted to your insurance company, that is not legal. You have rights that need to be protected and you have a right to receive compensation from your insurance company for damages. It is a really good idea to educate yourself about what you are entitled to and what you deserve to have. The fact is that you have been paying into your insurance to ensure that you are covered. You are not asking for something for free. You are asking for what you are entitled to have if you need it.