My insurer refuses to cover my prescribed treatment. What can I do?
If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:
- Appeal the decision;
- Request an external review; and
- File a complaint.
How do I request an appeal?
If your insurer denies your claim, you have the right to an internal appeal. This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:
- Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
- Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
- Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
- Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
- Request an expedited internal appeal, if applicable. Expedited internal appeals are available for emergency or life-threatening situations. Contact your insurer immediately and ask for instruction on how to request an expedited internal appeal if you believe your situation qualifies.
- Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
- Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.
How long should the internal appeals process take?
The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.
In which circumstances can I apply for an external review?
During an external review, an independent third party reviews your insurer’s decision.
Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to an external review if your insurer denies your coverage after an internal appeal.
You are entitled to expedited external review if your medical situation is urgent and waiting 30 to 60 days for the requested treatment would jeopardize your life or ability to function. If you qualify for an expedited external review, you can skip the internal appeals process.
How do I request an external review?
Alabama participates in the external review process administered by the U.S. Department of Health and Human Services. You can obtain an external review request form by calling (800) 866-6205 and, once complete, you can fax it to (888) 866-6190 or mail the completed form to:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.
You must file your written request for an external review within 60 days from the date that your insurer sent you the final decision.
How long will the external review process take?
The external review process should take no more than 60 days. If you requested an expedited external review, the process should take no longer than four business days after your request is received.
How do I file a complaint?
If you are an Alabama resident and you have completed the external review process but still lack access to a treatment, you can file a complaint with the Alabama Department of Insurance (“Department”).
Your complaint should include the following information:
- The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
- The name of the insured individual, if different from the Complainant;
- The names of any other parties involved in the claim (for example, the plan administrator or pharmacy benefit manager);
- The name of insurance company and the type of insurance;
- The state where the insurance plan was purchased;
- Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
- The reason for and details of the complaint; and
- What you consider to be a fair resolution.
You should also submit the following documents as supporting information:
- A copy of your insurance card;
- Copies of coverage denials or adverse benefit determinations from your insurer;
- Copies of any determinations made by internal and external reviewers;
- Any materials submitted with prior appeals and complaints;
- Supporting documentation from your health care provider;
- A copy of your insurance policy; and
- All responses from your insurer.
How to submit
The complaint may be submitted online here, faxed to (334) 956-7932, or mailed to the following address:
Alabama Department of Insurance
Consumer Services Division
P.O. Box 303351
Montgomery, AL 36130-3351
What happens after the Department receives my complaint?
The Department will research, investigate, and resolve your complaint. The Commissioner of Insurance will examine your account, records, documents, and transactions. The Commissioner may question witnesses, request additional documents from other parties, and hold a hearing. If the Commissioner determines that the insurer violated Alabama laws or regulations, it may order the insurer to give you the requested coverage or compensate you.
Who should I call if I have any questions about filing a complaint?
You can contact the Alabama Department of Insurance at (334) 241-4141. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.
 Appealing a Health Plan Decision: How to Appeal an Insurance Company Decision, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 25, 2016).
 Complaint to Federal Government Agency: Patient, Legal Action Ctr., https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).
 Ala. Code Ann. §§ 27-2-7, 27-2-19 (2016); see also Consumer Services Division, Ala. Dept. of Ins., http://www.aldoi.gov/Consumers/ConsumerServicesBio.aspx (last visited Oct. 17, 2016).
 Ala. Code Ann. § 27-2-20 (2016).
 Ala. Code Ann. § 27-2-26 (2016).
 Ala. Code Ann. § 27-2-7 (2016).