Iowa

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.
  • 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 between 30 and 60 days.[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. You can request an external review if:

  • You completed the internal review process or your insurer did not provide you with a decision on your internal appeal within 30 days of your request; and
  • Your insurer denied your requested treatment or service for one of the following reasons:
  • The service or treatment failed to meet your insurance company’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or
  • The insurer deemed the service or treatment experimental or investigational.[4]

You can skip the internal appeals process and request an expedited external review in the following circumstances:

  • Your health care provider certifies that completing the internal appeals process or waiting the standard 45 days for an external review would seriously jeopardize your life, health, or ability to regain function;
  • Your insurer denied your requested treatment or service because it is experimental or investigational and your health care provider certifies in writing that the service or treatment would be significantly less effective if not promptly initiated; or
  • You requested one of the following emergency services and you have not yet been discharged from the facility:
    • An admission;
    • Availability of care;
    • Continued stay; or
    • A health care service.[5]

How do I request an external review?

You should submit your request for an external review to your health insurer within 180 days from when your insurer sent you the final decision.[6]

Information

You can obtain the external review packet online here. You should include the following information in your application:

  • The name, address, telephone number, and email address of the patient;
  • The name, address, telephone number, fax number, and email address of the insurance company;
  • The employer’s name;
  • The name and address of the treating health care provider, as well as the name, telephone number, and email address of the contact person; and
  • The reason for the health insurer’s denial.

Supporting documents

You should submit the following supporting documents with your completed external review request:

  • Signed medical records release form (included in packet); AND
  • Any documentation not previously submitted during the internal appeal process; AND
  • Final determination letter from the health insurer; OR
  • Letter from health insurer stating it has waived the internal review process; OR
  • A copy of the request for internal appeal and a statement that no decision has been received for 30 days; OR
  • A completed request for expedited review (included in packet).[7]

How to submit a request for a standard external review

If you are requesting a standard external review, you can submit the form and copies of all supporting documents by fax to (515) 281-3059, by email to iid.marketregulation@iid.iowa.gov, or by mail to:

Iowa Insurance Division
Two Ruan Center
601 Locust St., 4th Floor
Des Moines, IA 50309[8]

How to submit a request for an expedited external review.

If you are requesting an expedited external review, you must call the Iowa Insurance Division at (877) 955-1212 or (515) 281-6348 to receive instructions on the quickest way to submit the form and supporting documentation.[9]

How long will the external review process take?

The external review process will take no more than 60 days.[10] If you requested an expedited external review, the process takes no longer than 72 hours after your request is received by the independent review organization.[11]

How do I file a complaint?

If you are an Iowa resident, you can file a complaint with the Iowa Division of Insurance (“Division”).

Complaint information

You can obtain the complaint form here. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of the insured individual, if different than the applicant;
  • The name of insurance company;
  • Policy number, claim number, and date of loss or service;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents

You should submit the following supporting documents along with the complaint form:

  • 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.[12]

How to submit

The complaint may be submitted online here, faxed to (515) 281-3059, or mailed to the following address:

Iowa Insurance Division
Market Regulation Bureau
601 Locust Street, 4th Floor
Des Moines, IA 50309-3738[13]

What happens after the Division receives my complaint?

Once you file your complaint, the Division will send you an acknowledgment letter. The Division will then request a response from your health insurer and begin reviewing the information. If the Division finds that the health insurer has violated a law, the Division will request that the insurer provide you with coverage or reimburse you. The Division may also order the insurer to pay a fine.[14] A final decision in your case may take up to six weeks.[15]

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

You can contact the Iowa Division of Insurance at (877) 955-1212 or (515) 281-5705. The Division is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.


[1] Appealing a Health Plan Decision: How to Appeal an Insurance Company Decision, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 27, 2016).

[2] A Consumer’s Guide to Internal Appeals and External Reviews, Iowa Insurance Division, http://insuranceca.iowa.gov/health/aconsumersguidetoappealsandexternalreview.pdf (last visited Nov. 27, 2016).

[3] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 26, 2016).

[4] Id.

[5] Iowa Code § 514J.106 (2016); A Consumer’s Guide to Internal Appeals and External Reviews, The Iowa Insurance Division, Consumer Advocate Bureau (June 2012), http://insuranceca.iowa.gov/health/aconsumersguidetoappealsandexternalreview.pdf.

[6] A Consumer’s Guide to Internal Appeals and External Reviews, Iowa Insurance Division, http://insuranceca.iowa.gov/health/aconsumersguidetoappealsandexternalreview.pdf (last visited Nov. 27, 2016).

[7] External Review Request Form, Iowa Insurance Division, http://www.iid.state.ia.us/sites/default/files/page/2010/07/28/extrevreqest_pdf_97809.pdf (last visited Nov. 27, 2016).

[8] Id.

[9] Id.

[10] Iowa Code § 514J.107 (2016).

[11] Iowa Code § 514J.108 (2016).

[12] 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).

[13] Consumer Complaint, Iowa Insurance Division, http://www.iid.state.ia.us/sites/default/files/page/2010/07/28/consumer_complaint_form_pdf_14642.pdf (last visited Nov. 27, 2016).

[14] Enforcement Bureau, Iowa Insurance Division, http://www.iid.state.ia.us/enforcement (last visited Nov. 27, 2016).

[15] Tips to Resolve a Complaint, Iowa Insurance Division, http://www.iid.state.ia.us/tips_to_resolve (last visited Nov. 27, 2016).