Health Insurance and Managed Care Appeal and Grievance Information for Patients.

Table of Contents

Overview.

Connecticut: External Appeals.

New York: Appeals and Grievances.

Pennsylvania: Complaints and Grievances.

We will be adding additional states to this page so please check back from time to time.

Overview.

An increasing number of states have passed laws giving consumers the right to obtain reviews of decisions by their health plans. Sometimes these reviews are called grievances and sometimes appeals, depending on the state and the type of issue involved. Most states which have passed these laws only give a patient the right to obtain a review of the original decision by persons associated with the health plan although an increasing number of states have also passed legislation which guarantees a patient the right to appeal certain decisions to independent review organizations or government agencies which are not affiliated with the patient’s health plan.

Laws in this area differ from state to state. In addition, not all health plans are subject to the laws of the states in which they operate. Check with someone knowledgeable about your health plan to find out if these state laws apply to you. Below are links to information on how patients can obtain reviews of insurance denials in different states. We will be adding to this list so check back from time to time.

Connecticut: External Appeals.

The Connecticut Insurance Department External Appeal Consumer Guide  discusses internal and external appeals available to patients who have had claims denied by Managed Care Organizations. The form for requesting an external appeal can be downloaded from the Consumer Guide.To reach the Consumer Guide, click on the link to the Connecticut Insurance Department home page HERE. On the homepage, click on DIRECTORY at the bottom of the page or in the list in the frame on the left hand side of the page. On the Directory page, scroll down to LIFE AND HEALTH DIVISION and under RELATED TOPICS/CONSUMER INFORMATION there is a link entitled EXTERNAL APPEAL CONSUMER GUIDE which links to the Guide.

New York: Appeals and Grievances.

Health Insurance and Managed Care Appeal and Grievance Information for Patients in New York. Read the article from our January, 1999 newsletter.

Patients Will Be Able to Appeal Health Insurance Denials to Independent Reviewers Under a New Law in New York which Becomes Effective July 1, 1999. Read the article from our January, 1999 newsletter.

Pennsylvania: Complaints and Grievances.

The Pennsylvania Department of Health Act 68 Managed Care Brochure describes complaint and grievance procedures for enrollees in managed care plans. It also provides contact information for the Pennsylvania Insurance Department for complaints involving Preferred Provider Organizations that do not require the use of a primary care physician gatekeeper or for traditional indemnity insurers

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