There are also many external influences on any plan's appeals process, so be sure to review any state or federal regulations about appeals processes. Many states require that a health care professional with appropriate expertise participate in the appeals process, and some states explicitly limit the authority of nonphysicians to deny claims. States have also adopted an array of policies to promote the physician's role in informing patients and assisting them in the appeals process. Laws in some states specify a role for physicians, recognizing that they may appeal a claim on behalf of a patient. Many states protect a physician's right to advocate for medically appropriate care by prohibiting plans from disciplining a provider who advocates for such care and by defining advocacy broadly enough to include the appeal of a plan's denial of treatment.
Some states have consumer groups available to assist patients with appeals.
Know your strategy. If you can convince the health plan to view the appeal as a chance to better serve the customer, you may improve your chances of achieving a satisfactory outcome. Customers who change plans rather than appeal denials are among the biggest threats to a health plan's viability. Most plans' appeals processes allow the patient to attend at least one appeal hearing. If you can't reach the medical director, try to reach someone at a supervisory level.