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Appealing a Decision Made by Your Health Insurer
When you receive a medical service, like a check-up with a doctor or an emergency room visit, you or your health care provider will submit a request for payment to your health insurer. This request is known as a claim.
If your claim is initially denied, you may be able to get the claim paid by taking the following steps. If you need care immediately, view the expedited external appeal section.
Step 1: Internal Appeal to your insurer
Ask your insurer to conduct a full and fair review of its initial decision. This is called an internal appeal.
- The denial notice you received will tell you the process you must follow, including how long you have to submit the internal appeal to your health insurer. Failure to submit your appeal within the timeframe listed in the notice may invalidate your claim. Call your health insurer if you do not understand how to submit an internal appeal.
- After you submit your internal appeal, your health insurer is required to tell you its final decision within:
- 30 calendar days for a health care service that has been scheduled but you have not yet received (a pre-service denial).
- 60 calendar days for a health care service you have already received (a post-service denial).
Step 2: External Appeal to DIFS
If you disagree with your insurer’s final decision, you may submit an appeal to DIFS. This is called an external appeal.
- The appeal must be submitted within 127 days of the final decision.
- External appeals can be filed with DIFS using either the online form or the paper form (PDF).
- You may file your own appeal or you may authorize another person, such as a doctor, attorney, parent, or spouse, to represent you.
- Be sure to include the following with your appeal:
- A copy of the final denial from your health insurer;
- The reason(s) why you are appealing the decision; and
- Any documentation you have to support your appeal.
- When the DIFS external appeal process is completed, both you and the insurer will receive written notice of DIFS’ decision.
Expedited Appeals
If your claim has been denied and you need care immediately to protect your life, health, or ability to regain maximum function, you may be able to file a DIFS expedited external appeal.
- An expedited external appeal is conducted by DIFS within 72 hours.
- Expedited external appeals can be requested using either the online form or the paper form (PDF).
- Your appeal must include a letter from your treating physician verifying the necessity of an expedited review.
- You can only request an expedited external appeal for pre-service denial. Post-service denials are not eligible for an expedited appeal.
For more information about the DIFS external appeal process, contact DIFS at 877-999-6442, Monday through Friday from 8 a.m. to 5 p.m.
Health Insurance Appeals Forms
Frequently Asked Questions
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I received an “adverse determination” on my health claim. What does that mean?
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How do I file a request for external appeal? Is there a time limit for filing?
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Who is able to file an appeal for a health service denial?
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How long does the appeal process take?
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Can I appeal the denial of a health care service that was considered experimental and/or investigational?