Contractual coverage-medical necessity-administrative issue

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Reference no: EM13901412

Researchers studied the outcomes of appeals from 1998 through 2000 (Studdert and Gresenz, 2003; Gresenz and Studdert, 2004). The researchers abstracted information from 3,519 appeals lodged against two of the largest health maintenance organizations (HMOs) in the country. The enrollees were disputing the plans’ decisions.

Of the appeals, 1,774 were pre-service appeals (Studdert and Gresenz, 2003). Preservice denials occur before the services enrollees are seeking have been provided. The researchers classified the pre-service appeals into five types: out-of-network, contractual coverage, medical necessity, administrative issue, and not evident reason. Enrollees were most likely to win appeals in cases in which the reason for the denial was not evident (52.7 percent) or which involved medical necessity (52.2 percent). Enrollees were least likely to win cases involving contractual coverage (33.2 percent). Overall, enrollees won appeals in 41.9 percent of the cases.

What is your recourse if your health care is denied?

Reference no: EM13901412

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