CMSA Today - Issue 4, 2016 - (Page 22)

Insurance Understanding the Health Insurance Appeals Process for Case Managers BY GARRY CARNEAL, JD, MA, AND JULIE O'BRIEN, RN, BSN, MS U nderstanding the appeals process for health insurance coverage is a critical requirement for case managers. Whether you represent a patient, provider, payer, or any combination thereof, navigating this complex process is an invaluable skill. Over the years, an array of regulatory requirements have been enacted to ensure that the process to appeal an adverse benefit determination is orderly and effective. The good news is that these regulations include many protections for both patients and ordering providers who need to file an appeal. However, the details governing how and when you file an appeal can vary widely depending on a myriad of different factors. The result is a complex appeals process due to various regulations, the plan offering, and appeal type. This article provides some perspective to help case managers navigate this complex process. UNDERSTANDING THE APPEALS PROCESS All 50 states and the federal government have adopted regulations to allow insured individuals, providers, and designated representatives to file appeals for adverse coverage determinations, also called "adverse benefit denials." In recent years, policy makers and other have focused on how health plans make coverage determinations, including how the appeals process addresses situations where the requested care is not authorized or payment is denied after the fact. The additional peer review stems from increasing pressure to cover expanded medical services due to the passage of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Medical services are getting more complicated 22 CMSA TODAY Issue 4 * 2016 Internal Appeals * UM Appeal * Timing Expedited vs. Standard * Type: Prospective, Concurrent, Retrospective * Administrative/Grievance Procedure Appeal * Parity Appeal External Appeals * * * * * External Review Appeal Regulator Complaints Accreditation Audits Arbitration Hearing Judicial Hearing and the health care dollar is being squeezed tighter. As a result, more complaints and class action lawsuits are being filed against health plans asserting utilization management and mental health parity violations. In addition, regulators and state attorney general officials are fining health plans for similar violations. The confluence of these factors makes it apparent that an orderly appeals process not only protects consumers and providers but also protects health plans from a risk management perspective. Therefore, health plans must take a more proactive approach to managing the appeals process. Arguably, everyone benefits from knowing how to file and process an appeal. APPEALS TYPES A number of appeal types and levels have been established over the years. These include: * Internal Health Plan Appeals 0 Clinical/Utilization Management (UM) Appeals (e.g., "medical necessity" appeals) 0 Administrative/grievance procedure appeals (e.g., payment or scope of coverage related to the plan documents disputes) 0 Mental health parity appeals 0 Other specialty appeals * External appeals 0 External review 0 Regulator complaints 0 Accreditation audits 0 Arbitration hearings 0 Judicial proceedings With all of the different dynamics associated with appeals, such as where to file, time frames, what to submit as documentation and so on, it is important to understand the different levels of appeals and the filing requirements. Below is some general guidance in a "Q&A" format to help case managers understand how the internal and external appeals process works. INTERNAL APPEALS What is a clinical UM appeal? A utilization management (UM) appeal allows patients,

Table of Contents for the Digital Edition of CMSA Today - Issue 4, 2016

President’s Letter
Association News
CMSA Corporate Partners
Triple Aim Requires Case Management “Target” Practice
Finding the “Right” Care Management System: “Must Have” Requirements + Structured Demonstration Process
Understanding the Health Insurance Appeals Process for Case Managers
Keeping the “Professional” in Professional Case Management
Patients Get Better Care When Doctors, Hospitals and Insurers Share a Common Interest
Index of Advertisers

CMSA Today - Issue 4, 2016