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

d 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."

About NAIRO

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
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SOURCE NAIRO
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