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 internal 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 in emergency situations. Your situation is an emergency if waiting 18 days for the requested treatment would jeopardize your life or health. 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?
Your insurer should provide you a response within 18 business days after your appeal is received. If you requested an expedited internal appeal, your insurer should provide you with a response within 72 hours of receiving your appeal.
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 denied your coverage for one of the following reasons:
- Your insurer determined that the treatment or service was not medically necessary or appropriate;
- Your insurer determined that the treatment or service was investigational or experimental; or
- Your insurer did not provide you with a decision on your internal appeal within18 hours for standard appeals or 72 hours for expedited appeals.
You are entitled to expedited external review if:
- Your medical situation is urgent and waiting 18 days for the requested treatment would jeopardize your life or ability to function; or
- The appeal decision concerns an admission, availability of care, continued stay, or health care item or service for which you have received emergency services but have not been discharged from a facility.
How do I request an external review?
You should submit your request for an external review to your health insurer. Your health insurer will submit your request to a qualified external review agency for consideration. You will have an opportunity to send any documentation that your insurance company does not already have, including, but not limited to, additional medical records, the opinion of your treating physician, and any peer-reviewed studies applicable to your situation. The external appeal agency will consider the following in making a decision in your case:
- Guidelines or standards used by the health insurer in making its original decision to deny services;
- Any personal health and medical information related to the condition for which treatment or medication has been denied to you;
- Your physician or health care provider’s opinion; and
- Your health insurance policy.
The external appeal agency may also consider the following in making its decision:
- Medical studies related to your condition;
- The results of professional consensus conferences;
- Practice and treatment guidelines;
- Government-issued coverage and treatment policies;
- Generally accepted principles of medical practice;
- Expert opinions;
- Peer reviews conducted by your health insurer; and
- The community standard of care.
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 appeal agency should respond to you within 21 business days. If you requested an expedited external review, then the agency should respond to your request within 72 hours after your request is received.
How do I file a complaint?
If your insurer denies your coverage after the external review process, you can file a complaint with the Alaska Division of Insurance (“Division”).
Your complaint should include the following information:
- The name, age, 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);
- The name of insurance company and the type of insurance;
- The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
- What you consider to be a fair resolution.
You should also submit the following supporting documents with your complaint:
- 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 (907) 269-7910, or mailed to the following address:
Alaska Division of Insurance
550 West 7th Avenue, Suite 1560
Anchorage, AK 99501-3567
What happens after the Division receives my complaint?
Within two weeks of filing your complaint, the Division should send you a letter with a file number and the name of the specialist assigned to investigate your complaint. The specialist will then contact your health insurer and attempt to resolve the issue.
Who should I call if I have any questions about filing a complaint?
You can contact the Alaska Division of Insurance, Consumer Services section at (800) 467-8785 (calling from within the state) or (907) 269-7900 (calling from outside the state). The Division 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/.
 Alaska Stat. § 21.07.020(6) (2016).
 Alaska Stat. § 21.07.020(5)(A) (2016).
 Alaska Stat. § 21.07.020(6)(A) (2016).
 Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 25, 2016).
 Alaska Stat. § 21.07.050 (h)(1).
 Alaska Stat. § 21.07.050 (2016).
 Alaska Stat. § 21.07.050 (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).
 Consumer Complaint, State of Alaska Div. of Ins., https://sbs-ak.naic.org/Lion-Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanishVersion=N (last visited Nov. 25, 2016).