Arkansas

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 appeal the decision?

If your insurer denies your claim, you have the right to an internal appeal.[1] 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.[2]
  • 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.
  • 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.[3]

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[4] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You can request an external review if your insurer denied your internal appeal because it determined that one of the following applied:

  • The requested services were not medically necessary;
  • The requested services were not medically appropriate;
  • An inappropriate level of care was requested;
  • The requested medical care would be ineffective; or
  • The requested services were experimental or investigational.[5]

You can request an expedited external review if you have an urgent medical condition. Your condition is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.[6]

How do I request an external review?

You should request an external review from the Arkansas Insurance Department (“Department”) within four months from the date that your insurer sent you the last decision.[7]

Request materials

You can find a copy of the request form here or you may call to request the form at (800) 852-5494. You should include any additional or new information and documentation not included with your request for an internal appeal with your request for an external review for consideration by the independent reviewer.

How to submit

The completed form should be mailed to:

Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, AR 72201-1904[8]

How long will the external review process take?

The external review process should take no more than 45 days. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[9]

How do I file a complaint with the Arkansas Insurance Department?

If you are an Arkansas resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The names of any other parties involved (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.[10]

Supporting documents

You should also submit the following supporting documents with your application:

  • 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.[11]

How to submit

The complaint may be submitted online here, faxed to (501) 371-2749, or mailed to the following address:[12]

Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, AR 72201-1904

What happens after the Insurance Department receives my complaint?

The insurance commissioner will assign someone to research, investigate, and resolve your complaint.[13] That person will examine your account, records, documents, and transactions.[14] He or she may question witnesses, request additional documents from other parties, and hold a hearing.[15] The commissioner will then provide you with a decision.

Who should I call if I have any questions about filing a complaint with the Insurance Department?

You can contact the Arkansas Insurance Department at (501) 371-2640 or (800) 852-5494. The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.

 How do I file a complaint with the Arkansas Attorney General’s office?

After you file a complaint with the Insurance Department, you may then file a complaint with the Arkansas Attorney General’s Office.[16] To file a complaint with the Attorney General, complete this online form. A representative from the Attorney General’s Office may ask for copies of supporting documents.[17]

What happens after the Attorney General’s office receives my complaint?

Once the Attorney General receives your complaint, a representative will assign it to an investigator.[18] Within five business days, the investigator will send a copy of the complaint to your health insurer if mediation is appropriate or will provide you with information about other solutions.[19] Your health insurer has ten business days to respond to the complaint.[20] The Attorney General will then provide you with a decision.

 Who should I call if I have any questions about filing a complaint with the Attorney General?

You can contact the Attorney General’s Office at (501) 682-2007 or (800) 482-8982. The Attorney General’s Office is open from 7:30 a.m. to 6:00 p.m. Monday through Friday.