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 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 urgent care review, if applicable. If your situation is urgent, you can contact your insurer and ask for an urgent care review. Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.
  • 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.[2] If you requested an urgent care review, you should receive a response without 72 hours.

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to external review if your insurer denies your claim after the internal appeals process.

Additionally, you can skip the internal appeals process and request an expedited external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

How do I request an external review?

Florida participates in the external review process administered by the U.S. Department of Health and Human Services. You can request an external review form by calling (800) 866-6205 or you can find an external review request form online here. You should include any new information or documentation you have gathered since the internal appeal. Be sure to note whether you are requesting an expedited external review.

Once you complete the form, you can fax it to (888) 866-6190 or mail it to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.[5]

You must request 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.[6]

How do I file a complaint?

If you are Florida resident and your insurer denies your coverage after the external review process, you can file a complaint with the Florida Division of Consumer Services (“Division”).

Complaint information

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);
  • 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.

Supporting documents

You should 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.[7]

How to submit

You may submit the complaint and supporting documents online here. Alternatively, you can call in your complaint to (877) 693-5236 (in-state) or (850) 413-3089 (out-of-state). You can also email your complaint and supporting documents to consumer.services@myfloridacfo.com.[8]

What happens after the Division receives my complaint?

An investigator for the Division will contact your health insurer regarding your complaint. The investigator should resolve the complaint within 30 days.[9]

Who should I call if I have any questions about filing a complaint?

You can contact the Florida Division of Consumer Services at (877) 693-5236 (in-state) or (850) 413-3089 (out-of-state). Division specialists are available to answer your questions 8:00 a.m. to 5:00 p.m., Monday through Friday.

[1] 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).

[2] Appealing a Health Plan Decision: Internal Appeals, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Nov. 25, 2016).

[3] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 25, 2016).

[4] Appealing a Health Plan Decision: Internal Appeals, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Nov. 25, 2016).

[5] Id.

[6] Id.

[7] Complaint to Federal Government Agency: Patient, Legal Action Center, https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx, (last visited Oct. 17, 2016).

[8] File an Insurance Complaint, Division of Consumer Services, http://www.myfloridacfo.com/Division/Consumers/needourhelp.htm (last visited Nov. 25, 2016).

[9] Id.