The People’s Medical Society (610-770-1670, www.peoplesmed.org) publishes a book called Medicare Made Easy and tells patients how to fight insurers’ denials.
       You can also call nonprofit groups geared to specific diseases, such as Cancer Care or the Alzheimer’s Association. And your state insurance department may be able to make recommendations.
       
STEPS TO TAKE IF YOU HAVE PRIVATE INSURANCE
       Each health insurance plan has its own guidelines for filing internal appeals, which are reviews conducted by the insurer itself. Your insurer should spell out its rules in the summary plan description that you get when you first enroll. Be sure to follow the rules precisely.
       If you lose your first internal appeal, you can generally file another one. Then if your insurer denies your claim again, you may be able to use your state’s external appeals process — if it has one. In an external appeal, your case will go before a review board usually made up of doctors and nurses with expertise in the procedure or treatment in question.
       The following states (plus the District of Columbia) offer external appeals: Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Vermont, and Washington. These states — Alaska, Maine, Massachusetts, South Carolina, and Wisconsin — also have enacted external appeals laws, but they have not yet taken effect.
       
WINNING YOUR REVIEW
       If you receive a final denial notice from your insurer, don’t wait long to explore your state’s appeals options. Each state has its own filing deadline. Call your state insurance office to find out how many days you have to file an appeal. Most states don’t charge consumers to file appeals, but in those that do the typical fee is $25 to $50. You’ll generally get a decision in 30 to 45 days, although external review boards will act more quickly if it’s a matter of life and death.        For details about your state’s external review process, ask your insurer and call your state insurance department (the number should be listed in the government pages of your telephone book). Or log on to the Insurance News Network’s Web site (www.insure.com).
       You cannot use your state’s external appeals process if you get health insurance through an employer who self-insures, however. Companies that self-insure cover their employees’ medical expenses themselves but often hire an insurance company to handle the paperwork. The federal Department of Labor, not state insurance departments or other state agencies, regulates self-insured health care plans, and there is no federal external appeals board.
       If your state doesn’t offer external review or if you don’t qualify for it, consider suing your insurer. Under the federal Employee Retirement Income Security Act of 1974 (ERISA), you can sue your health insurance company to try to get treatment that your insurer has denied. You can also sue for reimbursement if you paid for care yourself. You can’t sue for damages, however, except in a few states.
       
STEPS TO TAKE IF YOU’RE ON MEDICARE
       The procedure for Medicare appeals differs depending on whether you have traditional, fee-for-service Medicare or belong to a Medicare HMO. Here are each set of rules.
       If you have traditional Medicare:
       The first step is to determine whether your dispute involves Medicare Part A or Part B. Part A covers services provided by hospitals, skilled nursing facilities, and home health care agencies. Part B covers doctors’ and laboratory services, ambulances, and durable medical equipment like hospital beds and wheelchairs.
       If your claim falls under Part A, you have 60 days to request a review after receiving a summary notice that explains why Medicare denied your claim. It typically takes six to eight weeks for a Medicare intermediary — a private insurance company that processes and reviews Medicare claims dealing with Part A questions — to reconsider your case. If you lose, you’ve then got 60 days to request a hearing with an administrative law judge who works for the Social Security Administration. Your dispute must involve at least $100, and it may take up to a year to get a hearing date.
       You can appeal to the federal Department of Health and Human Services’ Departmental Appeals Board if you disagree with the administrative law judge’s decision. Your final stop is federal court, but you can take your case there only if it involves at least $1,000.
       If your claim falls under Part B, you have six months to request a review by a Medicare intermediary — after receiving a summary notice that explains why Medicare denied your claim. (If your dispute involves medical equipment, you appeal to one of four Durable Medical Equipment Regional Carriers.) You’ll typically get an answer in six weeks.
       If the answer is no, you’ve got six months to request a hearing before a hearing officer trained to understand medical issues and terminology. At least $100 must be in dispute. You can attend the hearing alone or with an attorney. If you lose again and at least $500 is in dispute, you’ve got 60 days to request a hearing before an administrative law judge. You can take your case to the Departmental Appeals Board if you disagree with the judge’s decision. Again, your final stop is federal court, but only if at least $1,000 is at stake.
       If you belong to an HMO:
       If you’re a member of a Medicare HMO, first ask your insurer for an internal review. You’ll typically get an answer within 30 days, but you can request a reply within 72 hours if your “life, health, or ability to regain maximum function” is in jeopardy. If your insurer still denies coverage, it must automatically send your appeal to the Center for Health Dispute Resolution, an independent agency that reviews Medicare HMO denials.
       If you lose again and more than $100 is at stake, you can request a hearing before an administrative law judge. After that, you can go before the federal Department of Health and Human Services’ Departmental Appeals Board, but only if more than $500 is in dispute. Finally, you can take your case to federal court if it involves more than $1,000.
       For more information, see the Medicare Rights Center’s Web site (www.medicarerights.org). You can also write to the center at 1460 Broadway, 11th floor, New York, NY 10036.