Appeals & External Reviews

There are two basic types of appeals:

• Coverage Appeals:
  If you are covered by a health insurance plan and your health insurance company denies a claim or authorization for treatment, you have a right to appeal the decision.
• Eligibility and Enrollment Appeals:
  If you are trying to enroll in a health insurance plan and you are denied coverage, you have the right to appeal.

The appeal process includes two types of reviews:

Internal Appeal:
You have 180 days from the date of the denial to initiate this appeal. To file an internal appeal, contact your insurance company by calling the number on the back of your insurance card. Individual plans allow for one level of internal appeal and group plans allow for two levels. See your policy or certificate for details.

External Appeal:
If a service or course of treatment is denied on the basis of not being medically necessary, you are entitled to request an external review. You are not eligible for external review if you are denied for a service not covered under your plan. You have 180 days from the date of the denial to request an external appeal. If you are covered under an insured plan you can request an external appeal through the NHID, which you can download from the NHID website at: https://www.nh.gov/insurance/consumers/documents/ex_rev_app.pdf. If your group plan is self funded by your employer, you should contact your human resource department.

The amount of time varies depending on the type of appeal you’re requesting:

• Internal appeals are generally completed within 30 days of the request. For urgent review, you may request an expedited appeal, the decision must be issued within 72 hours.
• External appeals may take more time. For non-urgent review, a decision is usually issued within 60 days. For urgent, expedited external appeals, a decision must be issued within 72 hours.