Kansas

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:

  • Request a first level and, if applicable, second level internal appeal;
  • Request an independent medical review; and
  • File a complaint.

 How do I request a first level internal appeal?

If your insurer denies your claim, you have the right to a first level internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To request a first level appeal, 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 do I request a second level internal appeal?

If you have a group plan and your insurer denies your claim after the first level internal appeal, you may have to request a second level internal appeal. During a second level internal appeal, you will have the right to appear in person and present your case directly to your health insurer’s representatives.[2]

Your health insurer must notify you if it offers a second level appeal. It will provide you with instructions on how to request the appeal and the deadline for filing the request.[3] It will also provide you with instructions on how to waive the second internal appeal if you decide you do not want to request one.[4]

How long should the internal appeals process take?

The first level internal appeals process should take no more than 60 days.[5] If you seek a second level internal appeal, the process should take no more than:

  • 72 hours if the appeal involves an emergency medical condition;
  • 15 business days if you have not yet received the requested service or treatment; or
  • 30 days if you have received the service or treatment but have been denied for reimbursement.[6]

In what circumstances can I apply for an independent medical review?

During an independent medical review (also referred to as an external review), an independent third party reviews your insurer’s decision.[7]

You can request an independent medical review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal but your insurer did not give you a decision within 60 days;[8] or
  • Your insurer denied you coverage because your insurer determined that:
    • The requested services were medically unnecessary, or inappropriate;
    • The requested services were experimental/investigational and ineffective;
    • You requested the wrong health care setting or level of care; or
    • Your plan was rescinded.[9]

You can request an expedited review simultaneously with your request for an internal appeal if you have an emergency medical condition.[10] Your condition is considered an “emergency medical condition” if:

  • Your condition is sudden, unexpected, and requires immediate medical attention;
  • If waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your health insurer has determined that the requested treatment is experimental or investigational; or
  • Your health care provider certifies in writing that the requested treatment would be significantly less effective if not initiated promptly.[11]

How do I request an independent medical review?

You can submit a request for an independent medical review to the Kansas Department of Insurance (“Department”) within 120 days of receiving a final decision from your insurer.[12]

Request form

You should contact the Department at (800) 432-2484 to request a copy of the Independent Medical Review request form.[13]

Supporting documents

You should include the following supporting documents with your request:

  • A letter summarizing your dispute,
  • Any new documentation that you had not included with your previous request for an internal appeal;
  • Copies of relevant medical records;
  • Your health care provider’s professional recommendation;
  • Consulting reports from other health care professionals and other documents submitted by your health insurer, you, or your health care provider;
  • Your insurance policy; and
  • All correspondence sent to you by your insurer.[14]

How to submit a standard request

To request a standard independent medical review, mail the form and supporting documentation to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612

How to submit an expedited request

To request an expedited independent medical review, contact the Department at (800) 432-2484 and ask for an independent medical review coordinator to help you with the process.[15]

How long will the independent medical review process take?

Within ten business days of receiving your request for an independent medical review, the Department will determine whether your situation qualifies for review by an independent review organization.[16] If your request is approved, the Department will forward your request to an independent review organization for further examination. A written decision will be issued to you within 30 business days. If you requested an expedited independent medical review, the process should take no longer than 72 hours after your request is received.[17]

How do I file a complaint?

If you are a Kansas resident and your insurer denies your coverage after the independent medical 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 (“applicant”);
  • The name of insurer;
  • Policy number, claim number, and date of loss; and
  • The reason for and details of the complaint.[18]

Supporting documents

You should also 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.[19]

How to submit

The complaint and supporting documents can be submitted online here, faxed to (785) 296-5806, or mailed to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612-1678[20]

What happens after the Department receives my complaint?

Once the Department receives your complaint, it will forward a copy to your insurance company for a response and send you a letter of acknowledgement.[21] If the health insurer has violated a law or regulation, the Department will request that the insurer take corrective action.[22]

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

You can contact the Department at (785) 296-7829 or (800) 432-2484. 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/ (last visited Dec. 1, 2016).

[2] Id.

[3] Kan. Stat. Ann. § 40-22a09a (2015).

[4] Id.

[5] Kan. Stat. Ann. § 40-22a14(d)(2) (2015).

[6] Kan. Stat. Ann. § 40-22a09a (2015).

[7] Health Insurance in Kansas, Kan. Ins. Dept. (July 1, 2015), http://www.ksinsurance.org/documents/department/publications/health-ins-in-kansas-2015.pdf.

[8] Kan. Admin. Regs. § 40-4-42g (2016).

[9] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Dec. 1, 2016).

[10] Kan. Code Ann. § 40-22a14 (2015); Kan. Admin. Regs. § 40-4-42d (2016).

[11] Kan. Code Ann. § 40-22a13 (2015); Kan. Admin. Regs. § 40-4-42d (2016).

[12] Independent Medical Review, Kan. Ins. Dept., (Jan. 2015), http://www.ksinsurance.org/documents/department/publications/independent-medical-review-2015.pdf.

[13] Id.

[14] Kan. Admin. Regs. § 40-4-42c (2016).

[15] Independent Medical Review, Kan. Ins. Dept., (Jan. 2015), http://www.ksinsurance.org/documents/department/publications/independent-medical-review-2015.pdf.

[16] Kan. Admin. Regs. § 40-4-42b (2016).

[17] Kan. Stat. Ann. § 40-22a15 (2015).

[18] Consumer Complaint Form, Kan. Ins. Dept., http://www.ksinsurance.org/documents/department/Complaint_Form.pdf (last visited Dec. 1, 2016).

[19] 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).

[20] Complaint Form, Kan. Ins. Dept., http://www.ksinsurance.org/documents/department/Complaint_Form.pdf.

[21] How to File a Complaint, Kan. Ins. Dept., (Jan. 2015), http://www.ksinsurance.org/documents/department/publications/how-to-file-a-complaint.pdf.

[22] Id.