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For Consumers > Health Insurance > Claim Appeals
 

GENERAL APPEALS INFORMATION:

Health and disability insurers in the state are required to provide a minimum of one level of internal appeal. Your insurer must notify you of your right to appeal when your claim is denied. You can file an appeal with your insurance company by writing or calling your insurance company. See below for more information on filing an appeal with your insurance company.

You can also file an appeal through the NH Insurance Department. You can file your appeal with the Insurance Department: (1) at the same time as you file an internal appeal at the insurance company, (2) after you have received an unfavorable decision from an internal appeal at the insurance company, or (3) with the Insurance Department without first filing an appeal with the insurance company or at the same time that you file an appeal with the insurance company.

The NH Insurance Department is required by law to certify independent external review organizations to review your appeal. The New Hampshire Insurance Department administers the processing of these appeals, and provides information and assistance to consumers about the process.

APPEALS THROUGH THE NH INSURANCE DEPARTMENT (EXTERNAL APPEALS)

New Hampshire law gives consumers the right to an independent external appeal when they have exhausted all appeals available through their health insurance company. However, expedited/urgent care appeals may be filed at the same time as the insurance company appeal. See below for information on appeals at the insurance company. The NH Insurance Department administers the external appeal process and certifies the independent review organizations ("ERO") that conduct the independent external reviews.

The ERO certification process ensures that independent review organizations and their network doctors have no conflicts of interest with the health insurance company or affiliate, the consumer, or the treating doctor or facility. In order to obtain certification, an external review organization must demonstrate it has a network of experienced and qualified medical doctors licensed in a variety of specialties. Physician reviewers must also demonstrate no conflicts of interest.

Click on the links below to obtain an application for external appeal and for additional information on the external appeals process.

CALL US TOLL FREE AT 1-800-852-3416 OR EMAIL US AT REQUESTS@INS.NH.GOV WITH QUESTIONS

APPEALS AT THE INSURANCE COMPANY

You have 180 days from the date your claim was denied to file an appeal with your insurance company. Insurance companies are required to offer at least one level of appeal, and may offer up to two levels of appeal. If you file an appeal with your insurance company, New Hampshire law requires your insurance company to make a decision on your appeal within the following time frames:

  • URGENT CARE/EXPEDITED APPEALS: Must be resolved as fast as the medical condition requires, but never longer than 72 hours. Urgent care means the patient's life or health, or the patient's ability to regain maximum function, would be seriously jeopardized if treatment/care is not received. Urgent care can include admission to a facility, or continued stay and health care services at a facility from which the patient has not been discharged. Urgent care/expedited external appeals may be filed with the Insurance Department at the same time as the urgent care/expedited appeal is filed with the insurance company.
  • NON-URGENT PRE-CARE APPEALS: Must be resolved within a reasonable time appropriate to the medical circumstances, but never longer than a total of 30 days (15 days if only one level of appeal is available through the insurance company).
  • POST SERVICE APPEALS: Must be resolved within a reasonable time appropriate to the medical circumstances, but never longer than 30 days for each level of appeal level available through the insurance company.

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New Hampshire Insurance Department | 21 South Fruit Street, Suite 14 | Concord, NH 03301
Phone 603.271.2261 | Fax 603.271.1406 | Consumer Hotline 1.800.852.3416

Copyright © State of New Hampshire, 2007