Self-Funded or Self-Insured Plan Appeals - FAQs

In short, a self-insured health plan is an employer-sponsored plan in which the employer assumes the financial risk for paying claims and providing benefits to its employees.

If you need help understanding the reasons your plan administrator denied a referral, a preauthorization request, or a claim, call your plan administrator’s Customer Service Department.  The administrator’s information is on the back of your insurance card.

You may appeal any denied or partially denied claim with your plan administrator.  You may also wish to contact your employer, as your employer may be able to approve payment of your claim.

If you need help understanding the appeal process or the types of adverse decisions which may be appealed, call your plan administrator’s Customer Service Department.  To file an appeal, submit a written request for reconsideration to your plan’s administrator or employer no later than 180 days from the date of the plan’s final denial.

Appeal decisions are usually issued within 20-30 days.

If your situation is urgent and delaying treatment will jeopardize your life or your long-term health, you and your treating physician may request an expedited appeal.  Expedited appeal decisions are usually issued within 72 hours.

Yes. A patient may designate an individual, including the treating health care provider, as his/her representative.

Each plan may have slightly different requirements. As such, it is important that you contact your plan administrator or employer for specific instructions. In general, the following documentation should be submitted:

• A photocopy of the front and back of the patient’s insurance card or other evidence the patient is insured by the company named in the appeal.
• A copy of the plan administrator’s letter, denying the requested treatment or service.
• Any medical records, statements from the treating health care provider(s) or other information that you would like the review organization to consider in its review.

If you have questions about your appeal rights, need additional assistance or wish to file a grievance concerning the administration of your appeal rights you may contact the Employee Benefits Security Administration at 866-444-EBSA (866-444-3272) or the U.S. Department of Labor at 866-487-2365.