Consumer’s Guides to Handling Disputes with your Employer or Private Health Plan

Generally, health plans are required to have specific procedures that you can follow to appeal a plan decision to deny or reduce coverage for your medical care. If you disagree with your health plan denial, typically you will begin with your plan’s internal appeals process to ask them to reconsider the decision. The rules governing your plan’s internal appeals process depend on what kind of health insurance you have (coverage you get from work or coverage you buy on your own) and where you live. If you’re not happy with the results of the internal appeals process, most states also provide for an external review process. In order to take advantage of your appeal rights, it is important to learn and follow the rules that apply in your situation.

The Henry J. Kaiser Family Foundation and Consumers Union have developed “A Consumer’s Guide to Handling Disputes with your Employer or Private Health Plan.” This guide will help you understand the type of coverage you have, what rules apply, and where to call for more information. To learn more about your appeal rights, follow this link to “A Consumer's Guide to Handling Disputes with your Employer or Private Health Plan” www.kff.org/consumerguide.

For more background information on state external review programs, the following reports were prepared by researchers at Georgetown University.

• Karen Pollitz, Jeff Crowley, Kevin Lucia, Eliza Bangit, "Assessing State External Review Programs and the Effects of Pending Federal Patients' Rights Legislation," (PDF) Report to the Kaiser Family Foundation, March 2002.

• Geraldine Dallek and Karen Pollitz, "External Review of Health Plan Decisions: An Update ." (PDF) The Henry J. Kaiser Family Foundation, May 2000.

• Karen Pollitz, Geraldine Dallek, and Nicole Tapay, "External Review of Health Plan Decisions in the States and Medicare ." (PDF) The Henry J. Kaiser Family Foundation, November 1998.