What is an administrative appeal?

An administrative appeal is a process that allows individuals to contest a decision made by an insurance company or agency, such as denial of coverage or a claim payment. In California, an administrative appeal is governed by the Knox-Keene Health Care Service Plan Act of 1975. According to the law, an administrative appeal must be made within 180 days of receiving the denial letter or claim notification. The appeal must include relevant documents and evidence to support the claim, such as medical records, doctor reports, and other relevant items. The appeal must also explain why the requested coverage or payment was denied, and provide details of the dispute. After the appeal is filed, the insurance company or agency must review it and either accept or reject the appeal within thirty days. If the appeal is rejected, the Knox-Keene Act provides for a second level of review, where the dispute is heard by an independent panel of experts, who then make a decision on coverage or payment. The decision is binding, so if the panel decides in favor of the individual, the insurance company or agency must comply and provide the coverage or payment requested. Administrative appeals can be complicated, and the rules governing them can be confusing, so it’s recommended that individuals seek legal advice if they are considering a dispute with their insurance company.

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