Resources for Health Insurance Appeals
The Nuts and Bolts of Appeals
Resources on ERISA (including information on the Aetna v. Davila and Cigna v. Calad
cases)
Medicaid Grievances, Appeals, Notices, and Fair Hearings
Tips for Assisting Consumers with Medicaid Appeals and Fair Hearings
A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005Update from the Kaiser Family Foundation and Consumers Union
Your Managed Care Rights and How to Appeal (AARP)
How to Appeal: What to Do If Your Medicare Plan Won’t Pay (AARP)
Medicare Appeals and Grievances (CMS)
MAXIMUS CHDR (the national Independent Review Entity for external reviews of Medicare
managed care denials)
Center for Medicare Advocacy
Arkansas Medicaid (other states may have similar material)
Consumer Information on Health Benefits Appeals from Washington DC’s Department ofHealth (other states may have similar material)
Sample Appeal Letters
Health Insurance Appeal Letters: A Toolkit for Clinicians (Sample Appeal Letters for Multiple
Sclerosis)
ERISA-Based Rules for Claims and Appeals
Employee Benefits Security Administration (which administers Employee Retirement Income
Security Act [ERISA] and the Health Insurance Portability and Accountability Act [HIPAA])
Final Claims Rule: Employee Retirement Income Security Act of 1974; Rules and Regulationsfor Administration and Enforcement; Claims Procedure; Final Rule [07/09/2001]
FAQs About the Benefit Claims Procedure Regulation
Medical Necessity Arguments
PubMed (NIH)
Public Library of Science (PLoS) Journals
New England Journal of Medicine
Journal of the American Medical Association
Annals of Internal Medicine
National Institutes of Health
National Guideline Clearinghouse (make sure the guidelines are current, less than five years
old)
Drugs@FDA (a catalog of FDA-approved drug products)
Medline Plus Drug Information
United States Pharmacopeia-Drug Information
The American Hospital Formulary Service Drug Information (the consumer’s physician may
have a subscription to this resource)
DRUGDEX Information System (the consumer’s physician may have a subscription to this
resource)
Patient organizations for disease/disorder (use a search engine like google.com to find them)
HIPAA Rights
HIPAA Privacy and Access to Medical Records Resource Center
Rights to Access Medical Records Under the HIPAA Privacy Regulation
Consumer Health Assistance Programs
Health Insurance Assistance Program Locator (to find one in your state)
Non-Profit Organizations
(if there is no consumer health assistance program in your area)
Caring Voice Coalition
Patient Advocate Foundation
Miscellaneous
Medline Plus (with a medical dictionary, medical encyclopedia, and other resources such as
local health services and patient organizations)
Aetna’s Clinical Policy Bulletins (other carriers may have similar websites)
MediLexicon (with a medical dictionary, medical abbreviations, and other resources)
CMS Internet-Only Manuals (IOMs) (day-to-day operating instructions, policies, and
procedures based on statutes and regulations, guidelines, models, and directives)
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