Free help with a health insurance appeal

• Your state’s Consumer Assistance Program

  Sponsor

  A state or territorial consumer assistance program, listed by the Centers for Medicare & Medicaid Services (CMS).

  Available help

  A program may help with health-insurance questions, complaints, and appeals. CMS says a state program may help you file an appeal or request a review; the services offered depend on the program.

  Plan applicability

  For consumers with health-insurance problems. Ask the program whether it handles your specific plan type and denial.

  Geographic and eligibility limits

  Programs are not available in every jurisdiction and their services vary. CMS’s state map lists available contacts and points to other resources where a program is not available.

  Official sources: CMS: Consumer Assistance Program and state map; CMS: Appealing health plan decisions

• Your state insurance department or regulator

  Sponsor

  The insurance regulator for your state or territory. The National Association of Insurance Commissioners (NAIC) provides a directory of regulator contacts.

  Available help

  The regulator can explain its complaint and appeal resources, help identify which review process may apply, and address insurer conduct within its authority. Some state processes handle external reviews.

  Plan applicability

  Primarily insurance products within that regulator’s jurisdiction. Authority depends on the plan and issue; ask the regulator if it oversees your coverage.

  Geographic and eligibility limits

  The office serves its own state or territory, and state rules differ. A regulator may not oversee every employer plan; ERISA-covered plans may instead involve the U.S. Department of Labor’s EBSA.

  Official sources: NAIC: State insurance department directory; CMS: External appeals and state processes

• Independent external review, when your plan allows it

  Sponsor

  External review is an independent review process. The federal process is administered for the U.S. Department of Health and Human Services (HHS) by MAXIMUS Federal Services.

  Available help

  An independent reviewer can reconsider an eligible denial after the required appeal steps. MAXIMUS also provides technical assistance for requests in the HHS-administered process. The federal process is available at no cost to the consumer; it is a review process, not general case advocacy.

  Plan applicability

  The HHS-administered federal process applies only when your plan participates and the denial qualifies. Other plans may use a state external-review process or another independent review organization.

  Geographic and eligibility limits

  Eligibility, who handles the review, and deadlines depend on the plan, state, and denial. Follow the instructions in your denial notice or ask your plan, state regulator, or Consumer Assistance Program which route applies.

  Official sources: CMS: HHS-administered Federal External Review Process; CMS / MAXIMUS: Federal external review request portal

• Employee Benefits Security Administration (EBSA)

  Sponsor

  The U.S. Department of Labor (DOL).

  Available help

  EBSA benefits advisers can discuss your rights if you believe an employer health plan did not follow ERISA requirements when handling a benefit claim.

  Plan applicability

  For employer-sponsored group health plans covered by the Employee Retirement Income Security Act (ERISA).

  Geographic and eligibility limits

  ERISA does not cover every employer plan or individual coverage. Contact EBSA about the nearest office and confirm that ERISA covers your plan; use your plan’s own appeal process and notice deadlines.

  Official sources: U.S. Department of Labor, EBSA: Filing a Claim for Your Health Benefits

• State Health Insurance Assistance Program (SHIP)

  Sponsor

  A local SHIP, a state program that receives federal support and is listed by Medicare.gov.

  Available help

  SHIPs offer free, personalized health-insurance counseling for people with Medicare. Medicare.gov includes SHIP under its guidance about getting help with an appeal.

  Plan applicability

  For people with Medicare, including those who need help understanding Original Medicare, Medicare Advantage, or Medicare drug-plan coverage.

  Geographic and eligibility limits

  SHIP is local, and the source does not establish what help a particular SHIP can provide with preparing or filing a specific appeal. Ask your local program about its services and follow the official Medicare instructions for your coverage.

  Official sources: Medicare.gov: Filing an appeal and getting help

For the general steps after a health-plan denial, return to the health-insurance appeal guide.