[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-301593-105":53,"doc-detail-301593-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","marketplace-appeals-process-presented-february-28-2018","Marketplace Appeals Process - Presented February 28, 2018","","Explains the marketplace eligibility appeals process presented on February 28, 2018, in partnership with the National Health Law Program (NHeLP). Covers when eligibility decisions can be appealed, the role of assisters, and how appeals are filed and carried out. Details the Federal Appeals Entity (FAE) rights for consumers in federal and state-based marketplaces, plus alternative resolution routes through CMS casework, insurer appeals, and State Department of Insurance (DOI) review.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":11,"@type":70,"position":76},"https://docshare.wps.com/template/presentations/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/marketplace-appeals-process-presented-february-28-2018/301593/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/marketplace-appeals-process-presented-february-28-2018/301593.png","ImageObject",442,249,{"name":88,"@type":89},"Mabel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-20","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Which consumers have the right to appeal marketplace eligibility determinations?","Question",{"text":108,"@type":109},"Consumers who disagree with certain eligibility determinations made by the marketplace have a right to appeal. 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Casework is available by request when the call center cannot answer an eligibility question or when it appears the call center has given an incorrect answer.\u003Cbr>• For more information, see July 2015 CMS Assister Webinar: CMS Casework Overview |  |  |\n\nInsurer Appeals  \nWhat are some types of issues can be resolved through the insurer?  \n• Provider was listed as in-network, but when attempting to use coverage, the provider doesn’t accept the consumer’s insurance  \n• Went to the emergency room and the consumer’s bill says the provider was out-of-network and payment is owed  \n• Insurer denied a claim for a covered service or procedure  \n• Insurer would not cover a prescription  \n• Insurer cancelled coverage  \n\n| Appeal to the Insurer |\n| --- |\n| If consumer has a problem with coverage of a health care service or other benefits decision made by the insurer\u003Cbr>• Internal Appeal: Within 180 days of receiving claim denial or adverse decision, ask insurer to conduct a full and fair review of its decision\u003Cbr>• External Appeal: Appeal to an independent 3rd party after completion of an internal appeal |\n\nState Department of Insurance (DOI)  \n\n| What are some types of issues that can be resolved by DOI?\u003Cbr>• Appealed the denial of a service with insurer which denied the appeal because:→ Not medically necessary (including appropriateness, healthcare setting, level of care or\u003Cbr>effectiveness);\u003Cbr>→ Experimental/Investigational; or\u003Cbr>→ Due to a pre-existing condition\u003Cbr>• Insurer incorrectly terminated coverag","cbCaiauFje9R9fcg","https://ap.wps.com/l/cbCaiauFje9R9fcg","pdf",3136933,42,"English","# Agenda\n## When an eligibility decision can be appealed\n## The role of assisters in appeals\n## The process for filing an appeal\n## How appeals decisions are carried out\n# Marketplace Eligibility Appeals\n## Federal marketplace appeals to HHS Appeals Entity (FAE)\n## State-based marketplace appeals then federal entity\n# What Determinations Can be Appealed\n## Not all issues can be appealed to the FAE\n# CMS Casework\n## When casework is appropriate\n# Insurer Appeals\n## Internal and external appeal timelines\n# State Department of Insurance (DOI)\n## Issues handled by DOI\n# Marketplace Appeals to FFM or SBM","[{\"question\":\"Which consumers have the right to appeal marketplace eligibility determinations?\",\"answer\":\"Consumers who disagree with certain eligibility determinations made by the marketplace have a right to appeal. Federal marketplace consumers submit appeals to the HHS Appeals Entity (FAE), while state-based marketplace consumers first appeal to their state’s entity and may then appeal to the federal entity.\"},{\"question\":\"What determines whether an issue can be appealed to the Federal Appeals Entity (FAE)?\",\"answer\":\"A determination must be final and of appropriate subject matter. Other non-appealable issues can be handled through CMS casework, appeals with the insurer, or by filing complaints with the state Department of Insurance.\"},{\"question\":\"How does the appeals process differ between insurer appeals, CMS casework, and DOI?\",\"answer\":\"CMS casework is used for complex eligibility/coverage issues when the call center and insurer cannot help, or when certain problems (like incorrect 1095-A information) require a fresh policy review. Insurer appeals address coverage problems via internal review within 180 days and then an external appeal to an independent third party. DOI handles certain service denials and discrimination-related issues, using information from the EOB or the insurer’s final denial of the appeal.\"}]","Marketplace Appeals Process - Presented February 28, 2018 | PDF"]