What is a network-level appeal?

A network-level appeal is a process that allows individuals to appeal a health plan’s decision to deny or limit coverage or payment of a healthcare service. This type of appeal is available to those who have health insurance through their employer, Medicare, or other type of contract in the state of California. When a network-level appeal is filed, a panel of health plan administrators or attorneys review the claim and decide whether or not the health plan should pay for the service. If the health plan denies or limits coverage, the individual has the right to file an appeal with the health plan to challenge the decision. During the appeal process, the health plan will provide an explanation for the decision and provide data and evidence to prove that decision was based on the policies and procedures of the health plan. The individual is also allowed to submit additional evidence during the appeal to demonstrate why they should be given the coverage or payment. Once the appeals panel has reviewed all the evidence, they provide their final decision which the health plan must follow. In California, individuals have the right to contact their state insurance commissioner’s office if they are not satisfied with their health plan’s decision on the network-level appeal. The state insurance commissioner has the authority to review the health plan’s decision and make a final decision on the appeal.

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What is a network-level appeal?

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