How Long Does It Typically Take for a Medical Necessity Letter to Get a Response?


Quick Answer

Response times for appeals vary by health plan provider, but certain health plans must adhere to time limits set by federal law, according to MedicalClaimsHelp.org. These periods are typically covered in the Evidence of Coverage section of the plan contract. Medical necessity letters specify the urgent nature of the appeal.

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Full Answer

The Department of Labor states that group health plans providing two levels of review following a denial are allowed a maximum of 15 days to reach a determination for pre-service claims at each level. Post-service claims are afforded a 30-day determination window. Both periods are subject to medical circumstances and the accuracy of the information received from the patient/doctor.

Pennsylvania Health Law Project notes that urgent claims filed with an expedited grievance or request for fair hearing must be resolved within 72 hours. This option is available for patients in a managed care plan.

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