Source: http://coveragerights.org/louisiana/
Timestamp: 2019-04-22 14:48:11+00:00

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How do I request an internal claims appeal?
Request an expedited internal claims appeal. You can file a request for an expedited internal claims appeal if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function or if your treating physician certifies that you may experience pain that cannot be adequately treated without the requested service or treatment. You can submit your request in the same manner as a standard internal claims appeal request.
Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Your request must be submitted within 180 days of receiving notice that your claim for treatment or service has been denied. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
How long should the internal claims appeal process take?
The internal claims appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement. An expedited internal claims appeal must be decided within 72 hours.
Denies your internal claims appeal.
You can also request an expedited external review if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function and you have also filed a request for an expedited internal claims appeal.
You must submit a written request for a standard external review directly to your health insurer within four months of your insurer’s last decision. If you are requesting an expedited external review, you should submit your request to your health insurer as soon as possible. You should include any new documentation or information with your request for an external review.
Once your insurer receives your request, it will ask the Louisiana Department of Insurance (“Department”) to assign the request to an independent review organization. Once an independent review organization receives notice that it will conduct your appeal, it will select one or more clinical peers to conduct the review. A clinical peer is a licensed physician or other health care professional in the same or similar specialty that typically manages the medical condition or treatment under review. You will then receive contact information for the review organization.
The external review process should take no more than 45 days from the date the independent review organization receives your request. If you request an expedited external review, the process should take no longer than 72 hours after your request is received by the health insurer.
If your claim involves an experimental or investigational treatment, the external review organization must provide written notice of its decision within 20 days of receiving the clinical peer’s opinion in a standard external review and within 48 hours in an expedited external review.
If you are a Louisiana resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.
After receiving your complaint, the Department will send you an acknowledgement letter, which will include your file number and the name of the compliance officer in charge of investigating your complaint. The compliance officer will send a copy of the complaint to your health insurer and request a response. If the Department is unsatisfied with the insurer’s response, the Department will continue the investigation. If the health insurer violated a law or regulation, the Department will take administrative action against the insurance company. The average complaint usually takes 45 days to resolve. You will receive periodic updates about the status of your complaint, or you can check the status online here.
You can contact the Louisiana Department of Insurance at (225) 342-5900 (local) or (800) 259-5300. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.
 See BCBS Claim Appeal Overview, http://www.insuranceclaimdenialappeal.com/2016/10/bcbs-claim-appeal-overview-standard.html (last visited Dec. 1, 2016).
 Consumer Guide to Health Insurance, Louisiana Department of Insurance, http://www.ldi.louisiana.gov/docs/default-source/documents/health/consumers-guide-to-health-insurance.pdf?sfvrsn=0 (last visited Dec. 1, 2016).
 Appealing a Health Plan Decision: Internal claims appeals, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Dec. 1, 2016).
 La. Rev. Stat. Ann. § 22:2435 (2016).
 Appealing a Health Plan Decision: External Review, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Dec. 1, 2016).
 La. Rev. Stat. Ann. § 22:2437 (2016).
 La. Rev. Stat. Ann. § 22:2434 (2016).
 La. Rev. Stat. Ann. § 22:2438 (2016).
 La. Rev. Stat. Ann. § 22:2392 (2016).
 La. Rev. Stat. Ann. § 22:2436 (2016).
 Complaint Report Form, Louisiana Department of Insurance, http://www.ldi.state.la.us/docs/default-source/documents/general-complaint-form.pdf (last visited Dec. 1, 2016).
 How to File an Insurance Complaint, Louisiana Department of Insurance, http://www.ldi.la.gov/docs/default-source/documents/publicaffairs/consumerpublications/file-a-complaint.pdf?sfvrsn=4 (last visited Dec. 1, 2016).
 Check Complaint Status, Louisiana Department of Insurance, https://www.ldi.la.gov/onlineservices/ConsumerComplaintForm/Complaints/ComplaintStatusLookup (last visited Dec. 1, 2016).

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