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. 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.
- 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 request an external review in the following circumstances:
- You requested an internal appeal from your insurer, but your insurer did not respond within the allotted timeframe;
- Your insurer denied your internal appeal; or
- Your health insurer denied your claim because it deemed your requested treatment “experimental” and you meet all of the following criteria:
- You have a terminal condition with a substantial probability of death within two years or your ability to regain or maintain function would be impaired;
- You have already tried standard treatments, your health care provider certifies that the standard treatment is not medically indicated for your condition, or there is no standard treatment more beneficial;
- Your health care provider recommends and certifies in writing that the proposed treatment is more beneficial to you than the standard treatment;
- You have requested a treatment and your health care provider has certified in writing that the proposed treatment is supported by scientific studies, using accepted protocols and published in peer reviewed literature, is likely to be beneficial to you than the standard treatment; and
- Your insurance policy states that the treatment should be covered, and the only reason it was not covered was because your insurer determined that it was experimental.
Additionally, you can skip the internal appeals process and request an expedited external review in urgent situations. 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?
To request an external review, you should submit a written request to the Georgia Department of Insurance (“Department”). Your insurer should have provided you with instructions on how to submit the request and what information, documentation, and procedures are required for external review of your case. If you cannot find the instructions, contact your insurer.
How long will the external review process take?
The external review process should take no more than 30 days. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the independent reviewer.
How do I file a complaint?
If you are a Georgia resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.
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 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; and
- The reason for and details of the complaint.
You should include the following supporting documents with your request:
- 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 and supporting documents may be submitted online here, faxed to (404) 657-8542, or mailed to:
Georgia Department of Insurance
2 MLK Jr. Drive, Suite 716, West Tower
Atlanta, Georgia 30334
What happens after the Department receives my complaint?
The Department will assign an investigator to your case. The investigator will then work with your health insurer and you to resolve the issue. If the investigator determines that the insurer violated a law or policy, it will take corrective action.
Who should I call if I have any questions about filing a complaint?
You can contact the Georgia Department of Insurance at (404) 656-2070 (in the Atlanta metro area) or (800) 656-2298 (outside the Atlanta metro area). The Department is open from 8:00 a.m. to 7:00 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).
 Appealing a Health Plan Decision: Internal Appeals, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Nov. 25, 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).
 Ga. Code Ann. § 33-20A-32 (2016).
 Appealing a Health Plan Decision: Internal Appeals, supra note 2.
 Ga. Code Ann. § 33-20A-37 (2016).
 Ga. Code Ann. § 33-20A-35 (2016).
 Ga. Code Ann. § 33-20A-35 (2016).
 Ga. Code Ann. § 33-20A-37 (2016).
 Helping Georgia Consumers with Insurance Issues, Office of Insurance & Safety Fire Commissioner, https://www.oci.ga.gov/ConsumerService/Complaint.aspx (last visited Nov. 25, 2016).