Navigation Links
Patients' Must Know Rights When Health Plans Deny Claims

WESTERVILLE, Ohio, Aug. 25 /PRNewswire/ -- Newspapers report daily that our healthcare system is broken, express concern about healthcare denials and mention that the system shifts costs to consumers. Commonly denied treatments include cosmetic surgeries, experimental/investigational drug therapies, pain management and chiropractic treatments according to NAIRO (, a trade organization of independent review organizations (IROs). Health plans claim they deny such cases based on whether the treatment is medically necessary, in network, covered by the medical policy or experimental/investigational.

"State laws give patients denied payment of treatment or services recourse for appeal," said Seana Ferris, President of NAIRO. "Unfortunately many healthcare consumers don't understand the process, don't know their right to appeal or quit too soon." Presently 44 states and the District of Columbia have external review legislation. NAIRO provides frequently asked questions about patients' rights on its Website at

Steps for Patient Appeal

By learning the steps in their health plan's and state's appeal processes, patients can escalate their appeal to appropriate agencies when necessary. "Patients denied payment of treatment must first exhaust the internal appeal process offered through their health plan," Ferris said. "Following the denial of an internal appeal, they can request an external review using a qualified and unbiased third-party, like a URAC-accredited IRO." Generally, the health plan, not the patient, bears the cost of an external review.

Ask Questions

To start the process, patients need to ask questions, like these:

  • What is the reason for the denial?
  • Did the health plan seek an independent medical review determination from an IRO before denying coverage?
  • What are the timeframes to make an appeal and what information is required?

States Decide the Process

IROs assist many leading health plans in making medical necessity determinations as a part of the plan's internal appeal process. Typically, this is a best practice among health insurers. However not all health plans conduct these arm's length reviews. When a health plan denies a benefit, consumers should inquire whether the plan conducted an objective review using an unbiased third party, like an IRO.

Once patients exhaust the internal review process outlined by their health plan, their rights hang on the type of claim denied and the state they live in. Their next step is to request an external review appeal following the process established by their state insurance commissioner.

Role of the IRO

IROs employ independent, credentialed and licensed healthcare practitioners with specialist credentials needed to perform an evidence-based review a case based on its medical necessity. The expert is board-certified, in active practice and has the knowledge and experience to perform an unbiased and thorough medical review of the case.

"Consumers today have many rights when it comes to healthcare denials," Ferris said. "They just need to learn the ins and outs of the appeal process and then see the process through to the end."


NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit

NAIRO officers are available for press interviews.

Copyright©2009 PR Newswire.
All rights reserved

Related medicine news :

1. First Swedish Patients Receive MitraClip(R) Therapy
2. Prostate Net Announces: Major Medical Education Initiative for Patients, Caregivers and Healthcare Professionals
3. Cancer patients who are separated when diagnosed have worse survival rates
4. Young leukemia and lymphoma patients live longer today than in years past
5. U-M researchers discover therapeutic target that could help patients with pulmonary fibrosis
6. Distressed Patients Suffer Panic Attacks as UK Medicine Stocks Hit by Shortages, Chemist+Druggist Reveals
7. Newer Drug Beats Tamoxifen for Older Breast Cancer Patients
8. Roche and InterMune Initiate Phase 2b Clinical Trial of RG7227/ ITMN-191 in Patients With Chronic Hepatitis C
9. Tumor size and level of visceral pleura invasion can impact survival of NSCLC patients
10. Study shows carvedilol is effective in preventing variceal bleeding in cirrhotic patients
11. Laurence Barsh, DMD, Founder of Snoring Isn't Sexy, LLC Emphasizes Need to Evaluate and Treat Sleep Patients
Post Your Comments:
(Date:11/30/2015)... ... November 30, 2015 , ... ... at the Radiological Society of North America (RSNA) 2015 conference. , Leading ... dictation and speech-enabled documentation software, announced their partnership today at RSNA 2015. ...
(Date:11/30/2015)... ... 30, 2015 , ... World Patent Marketing , a ... household invention that provides an economical and easy way of gaining customized curtains. ... at 2.6%," says Scott Cooper, CEO and Creative Director of World Patent Marketing. ...
(Date:11/29/2015)... St. Petersburg, FL (PRWEB) , ... November 30, ... ... beauty are available today from the new company, Sublime Beauty NATURALS®. All products ... organic and natural products, like essential oils, organic facial serums and USDA Certified ...
(Date:11/29/2015)... ... ... The Cyber Monday deal is a deep 40% or more discount on every item on ... the skin care lover in your circle. Each Christmas, Sublime Beauty offers a special ... serums are staples: Collagen, Retinol and Hyaluronic Serums. , Stocking stuffers like Skin Brushes, natural ...
(Date:11/29/2015)... , ... November 29, 2015 , ... While conventional walkers ... or provide ready access to exercise weights. Fortunately, an inventor from Uniontown, Pa., has ... TOMMY WALKER to enhance the benefits of a standard walker to improve the user’s ...
Breaking Medicine News(10 mins):
(Date:11/27/2015)... 27, 2015  Lannett Company, Inc. (NYSE: ... the acquisition of Kremers Urban Pharmaceuticals Inc. (KU), ... biopharmaceuticals company UCB S.A. (Euronext: UCB). ... acquired KU from UCB for total consideration of ... a customary working capital adjustment, a deduction of ...
(Date:11/26/2015)... november 2015 AAIPharma Services Corp./Cambridge ... investering aan van ten minste $15,8 miljoen ... het mondiale hoofdkantoor in Wilmington, ... in extra kantoorruimte en extra capaciteit voor ... behoeften van de farmaceutische en biotechnologische markten. ...
(Date:11/26/2015)... 3D bioprinting market is expected to reach ... by Grand View Research Inc. Rising prevalence of chronic diseases ... is expected to boost the market growth, as 3D bioprinting ... --> 3D bioprinting market is expected to reach ... by Grand View Research Inc. Rising prevalence of chronic diseases ...
Breaking Medicine Technology: