Exclusions from the Health Care Appeals Process
Those with coverage through a Medicare HMO, Medicare supplement plan, long-term care coverage, a multi-employer plan under ERISA, a federal employee plan, or any self-funded or self-insured plan are not eligible to participate in the appeals process described in this brochure. Workers’ Compensation claims and disputes are also not eligible for this appeals process. These other plans normally do have an appeals process of some kind that you may use, but the appeals process in those other plans will probably be somewhat different from what is described in this brochure. Issues concerning how you were treated by a provider, benefit reductions due to usual and customary charge limitations, deductibles, and coordination of benefits issues are also not eligible for health care appeals. If you merely have questions regarding your plan, you should call the member services department of your insurer.
You can obtain "Appeal Rights for Medicare HMO Beneficiaries" from https://www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.
We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.
Certain antivirus products will detect this as a malicious email. If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or [email protected].