1. Request for a review of an insurance claim that has been underpaid or denied by an insurance company to receive additional payment. Such requests are made to the health plan by the patient who is represented by the physician or provider who submitted the original insurance claim. Appeals to self-insured plans are submitted to the employer or U.S. Department of Labor. In some cases, an appeal may be submitted to the Department of Insurance of the state where the plan is located. 2. Redetermination process whereby the provider and/or beneficiary (or representative) exercises the right to request a review of a contractor’s decision to deny Medicare coverage or payment for a service in full or in part. Also called postservice appeals. See also preservice appeal and expedited appeal.
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The right of a party who has received an adverse decision to take the case to a higher court for review.