Idaho

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.[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.
  • 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.
  • Ask for an expedited urgent care request, if applicable. If your situation is urgent, you should ask your insurer for an expedited urgent care request. Your situation is urgent if waiting for 35 days for your requested treatment:
    • Could seriously jeopardize your life, health, or ability to regain function;
    • Could result in you experiencing severe and unmanageable pain; or
    • The requested treatment would be significantly less effective if it were delayed.
  • 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 35 days for a standard internal appeal and three business days for an expedited urgent care request.[2]

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.

Under Idaho law, you are entitled to request an external review in the following circumstances:

  • Your situation is urgent;
  • If you have not received a decision within 35 days if you requested standard internal appeal or within three business days if you requested an urgent care request;[4]
  • Your insurer denies your internal appeal.

Please note that if your situation is urgent, you do not need to wait for a decision from your insurer. You can request an expedited external review at the same time that you request an expedited urgent care request from your insurer.[5]

How do I request an external review?

You should submit your request for external review to the Idaho Department of Insurance (“Department”) within four months of the date on the final determination letter from your insurer.[6]

Information

You can find a copy of the external review request form here. You should include the following information with your request:

  • 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 name, address, and telephone number of the insurance company;
  • Policy identification number and claim number;
  • The insured individual’s employer name and telephone number;
  • The name, address, and telephone number of the patient’s health care provider;
  • The name of the contact person at the health care provider’s office; and
  • The reason for and details of the denial of coverage.

Supporting documents

You should include the following supporting documents with your request:

  • A signed medical release form (available here);
  • A photocopy of your insurance ID card or other evidence showing you are insured with the health carrier named in your request;
  • A copy of the final determination letter from your health carrier;
  • A copy of your certificate of coverage or policy benefit booklet, which lists the benefits under your health plan;
  • A signed “Certification by Treating Health Care Provider” form available in this packet (this form is for expedited external reviews only).[7]

How to submit a standard external review request

If you are requesting a standard external review, you should submit your request to the following address:

Idaho Department of Insurance
Attn: External Review
700 W. State Street, 3rd Floor
P.O. Box 83720
Boise, ID 83720-0043[8]

How to submit an expedited external review request

If you are requesting an expedited external review, you should contact the Department for instructions on how to submit required forms.[9] You can reach the Department at (208) 334-4250 or (800) 721-3272.

How long will the external review process take?

The external review process should take no more than 42 days from the date the independent review organization receives your request.[10] If you requested an expedited external review, the process should take no more than 72 hours after the independent review organization receives your request.[11]

How do I file a complaint?

If you are an Idaho resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.[12]

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 than the Complainant;
  • The name of insurance company;
  • Policy number, claim number, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents

You should 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.[13]

How to submit

You can submit the complaint and supporting documents online here, fax them to (208) 334-4398, or mail them to:

Idaho Department of Insurance
Consumer Affairs Section
700 W. State Street, 3rd Floor
Boise, ID 83720-0043[14]

What happens after the Department receives my complaint?

The Consumer Services Division of the Department will research, investigate, and resolve your complaint.

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

You can contact the Idaho Department of Insurance at (208) 334-4319 or (800) 721-3272. The Department is open from 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/ (Nov. 25, 2016).

[2] External Review Questions, Idaho Dept. of Ins., http://www.doi.idaho.gov/consumer/FAQ/ExternalReviewFAQ.aspx (Nov. 25, 2016).

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

[4] Id.

[5] Idaho Code § 41-5907(2)(c) (2016).

[6] External Review Request Form, Idaho Dept. of Ins., http://www.doi.idaho.gov/Consumer/Docs/External%20Review%20Form.pdf (Nov. 25, 2016).

[7] Id.

[8] Id.

[9] Id.

[10] Id.

[11] Id.

[12] File a Complaint, Idaho Dept. of Ins., http://www.doi.idaho.gov/consumer/Complaint.aspx (last visited Nov. 26, 2016).

[13] 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).

[14] Consumer Complaint Form, Idaho Dept. of Ins., http://www.doi.idaho.gov/Consumer/Docs/Report.pdf (last visited Nov. 26, 2016).