Glossary of Appeal Process Terms
These are commonly used appeal terms and definitions that may be included in the documents you send and receive. This is not a complete list and should be used for general information purposes only. Communication from your insurance plan or other third parties may use variations of these terms.
ADVERSE DETERMINATION
A letter from the health plan that informs the insured person that a benefit, claim or preauthorization request has been denied.
AUTHORIZED SERVICES
Services for whichthe health plan has approved access. Another term is precertified services.
CLAIMS ADJUSTOR
A representative of the health plan who reviews claims for benefits and first level appeals.
CONCURRENT REVIEW
A process in which medical care, the health care setting or discharge plans are monitored while in progress. The review determines appropriateness and coverage by the insurance plan.
CURRENT PROCEDURAL TEHCNOLOGY (CPT) CODE
A 5-digit code that identifies treatments and procedures performed by a medical provider. CPT codes and ICD-10 codes explain a patient’s diagnosis.
EXPEDITED REVIEW
An appeal is reviewed on a faster than normal pace when the treating physician makes the case that a delay in treatment will seriously affect the patient’s health. Sometimes called accelerated review.
EXPERIMENTAL OR INVESTIGATIONAL TREATMENT
Treatments not approved by the Food and Drug Administration or are outside of what is considered acceptable medical practice. These treatments or products are not covered by insurance plansand require a special exception.
EXTERNAL REVIEW
If an internal appeal has been unsuccessful, a patient can request an external review. The external review panel is made up of independent clinicians and insurance professionals. In some states, this review is managed by state Department of Insurance.
ICD-9 AND ICD-10 CODES
These six-digit code are used to describe a patient’s diagnoses. Usually combined with CPT codes.
INDEPENDENT REVIEW ORGANIZATION (IRO)
A panel of clinicians and insurance professionals that are not affiliated with the insurer and handle the third-level appeal or external review. The insurer must pay for treatment the IRO determines is necessary.
INTERNAL REVIEW
The process a patient can use to appeal the denial of a claim or a preauthorization request. It usually includes two levels of appeal.
MEDICAL NECESSITY
The term used to describe medical care that is required to appropriately treat a medical health condition and is considered accepted medical practice. Different insurers may have different ways to decide if a treatment is medically necessary.
OFF-LABEL USE
Prescribing a drug to treat a medical condition even though the Food and Drug Administration has not approved its use for this condition.Physicians do this because the drug has proven to be effective in clinical practice
POST-SERVICE DETERMINATION
The decision by your insurer to deny a claim and not issue payment after service has been rendered.
PRE-SERVICE DETERMINATION
The decision by your insurer to deny authorization of a service or deny a claim before or while service is being rendered (e.g., while a patient is in the hospital).
RIDER
A condition or additional provision that is added to a policy that changes the benefits provided.
UNTIMELY SUBMISSION
Insurers set a certain time frame for claims to be sent by health care providers for processing. If the claim isn’t filed in this time frame, the insurer may deny it.