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Idaho, Illinois Insured Gain Control Over Denials

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  • In Industry News
  • January 29, 2010
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Idaho and Illinois residents have been granted the legal right to externally appeal health insurance benefit denials. This brings the number of states without such a law down to just five: Mississippi, Nebraska, North Dakota, South Dakota, and Wyoming. The law, however, varies from state to state.

Idaho’s law, which went into effect Jan. 1, stipulates that an insurer must notify a member of his or her right to appeal a denial of payment. When the denial of payment is based on the grounds that the service is either medically unnecessary or investigational, a member may appeal to an accredited independent review organization within four months of the final denial from the insurer’s internal appeal process.
The independent review board must take into consideration the claimant’s medical record, recommendations and consulting reports from physicians and other health care professionals, appropriate practice guidelines, and any other available medical and scientific evidence.
“The law requires that the review be completed with 42 days under a standard review or 72 hours if the person’s treatment is urgently needed and he or she qualifies for an expedited review,” reports amednews staffer Emily Berry (Jan. 25).
For complete details of this law, refer to the Idaho Health Carrier External Review Act.
Under current state law, only Illinois health consumers who are enrolled in a Health Maintenance Organization (HMO) have the right to an independent, external review when claims are denied. Effective July 1, new legislation extends this right to all Illinois residents with health insurance coverage.
The insured will be able to appeal to an independent external review board claims denied on the grounds of medical necessity, appropriateness, care settings, level of care or effectiveness. “If payment for a treatment is denied on grounds that it is experimental, the person’s physician must certify that the treatment is medically necessary,” according to the online-only amednews report.
Illinoisans must also exhaust their insurer’s internal grievance process before appealing to an external review board, but not if waiting to do so would “increase the risk to a person’s health or significantly reduce the treatment’s effectiveness.”
And in Illinois, external review boards have only 20 business days to complete a review or, in urgent cases, 72 to 120 hours.
Refer to the Health Carrier External Review Act for complete details.

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