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Patients' Must Know Rights When Health Plans Deny Claims
Date:8/25/2009

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 (www.nairo.org), 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 www.nairo.org/patients-faq.php.

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

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SOURCE NAIRO
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