Complaints and Appeal Processes
The Affordable Care Act (ACA) provides any patient the right to an internal and or external review if coverage or benefits of service are denied by their health care plan.
Internal Appeal Request
When you request an internal appeal, your plan must give you its decision within:
- 72 hours after receiving your request when you’re appealing the denial of a claim for urgent care. (If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time.)
- 30 days for denials of non-urgent care you have not yet received.
- If your plan denies your request, you may seek an external appeal. Your plan must provide information on your denial notice about how to request an external appeal.
For additional information, visit http://www.healthcare.gov/law/features/rights/appealing-decisions/index.html.
How to File a Complaint If You Are Not Satisfied with the Services Your Child Has Received:
First, talk with your child’s pediatrician about your concerns, no matter who provided the services. A partnership based on open and honest communication is very important to meeting your child's health care needs. This can often reduce the number of problems you may have in making your managed care plan work for your family.
If you feel you need to file a complaint, call or write to the member service representative of your plan. See your plan handbook for information about filing a complaint. You also can contact your employee benefits manager for help.
- Last Updated
- American Academy of Pediatrics (Copyright © 2013)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.