Mississippi

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 of 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.[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 your insurer denies your claim after the internal review process because your insurer determined one of the following applied:

  • Your requested service or treatment was not medical necessity;
  • Your requested service or treatment was not appropriate;
  • Your requested an inappropriate health care setting;
  • You request an inappropriate level of care; or
  • Your insurer doubted the effectiveness of the health care service or treatment you requested.[4]

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function.[5]

How do I request an external review?

You should file your request for an external review with the Mississippi Insurance Department (“Department”) within four months from when your insurer sent you the final decision.[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 of the person submitting the application;
  • The name, address, and telephone number of the insured;
  • The name of the patient (if different from the insured individual);
  • The name, address, and telephone number of the insurance company;
  • The insurance identification number and claim number;
  • The name and telephone number of the insured individual’s employer;
  • The name and address of the treating health care provider;
  • The name and telephone number of the contact person at the health care provider’s office;
  • The medical record number;
  • The reason for the denial;
  • A brief description of the claim; and
  • A description of the health care or treatment decision in dispute.[7]

Supporting documents

You should also submit the following supporting documents:

  • A signed medical records release form (included in the external review form packet);
  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of your insurance policy;
  • Any new information and documentation not included with your original request for an internal appeal; and
  • The health care provider certification form located in the external review packet (this form is for expedited external review requests only).[8]

Submitting a standard external review

If you are requesting a standard external review, you should mail the completed form and supporting documents to the following address:

Office of the Insurance Commissioner
Mississippi Insurance Department
Attn: Life and Health Actuarial Division
P.O. Box 79
Jackson, MS 39205[9]

Submitting an expedited review

If you are requesting an expedited external review, you should call the Department at (601) 359-3569 and ask for instructions on the fastest way to submit your request.[10]

How long will the external review process take?

If the insurer determines that your requested treatment is “experimental,” the expedited external review process should take no more than five days and the standard external review process should take no more than 20 days.[11]

If the insurer denies your request for any reason other than the treatment being experimental, the expedited external review process should take no more than 72 hours and the standard external review process should take no more than 45 days.[12]

How do I file a complaint?

If you are a Mississippi resident and your insurer denies your claim after the external review process, you can file a complaint with the Department.

Complaint information

Your complaint should include the following information:

  • The name, address, email address, telephone number of the person filing the complaint (“Complainant”);
  • The Complainant’s relationship to the insured individual;
  • The name, address, email address, and telephone number of the insured individual, if different than the Complainant;
  • The name and address of the insurance company;
  • The policy number, claim number, and date of loss;
  • The reason for the complaint; and
  • The details of the complaint.[13]

Supporting documents

You should also submit the following supporting documents:

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Copies of explanations of benefits received;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[14]

How to submit

The complaint may be submitted online here, faxed to (601) 359-1077, or mailed to the following address:[15]

Mississippi Insurance Department
Attn: Consumer Services Division
P.O. Box 79
Jackson, MS 39205

What happens after the Department receives my complaint?

Once the Department receives your complaint, you will receive an email acknowledgement and the complaint identification number.[16] The Department will provide a copy of your complaint to your health insurer. The complaint will then be reviewed by the Consumer Services Division, which will make a decision regarding your issue.[17] The process will take a minimum of 20 business days.[18] The Department can force your health insurer to comply with the policy, or issue a citation or fine if the insurer has violated a law or regulation.

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

You can contact the Department at (601) 359-2453 or (800) 562-2957. 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 Nov. 27, 2016).

[2] Appealing a Health Plan Decision: Internal Appeals, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (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] Health Care External Review, Miss. Ins. Dept., http://www.mid.ms.gov/healthcare/external-review.aspx (last visited Dec. 5, 2016).

[5] External Review Request Form, Miss. Ins. Dept., http://www.mid.ms.gov/healthcare/pdf/ExtRevApp.pdf (last visited Nov. 27, 2016).

[6] Id.

[7] Id.

[8] Id.

[9] Id.

[10] Id.

[11] Miss. Ins. Dept., Bull. No. 2012-5, Compliance Requirements for Mississippi Health Carrier External Review Regulation (January 1, 2013), http://www.mid.ms.gov/legal/bulletins/20125bul.pdf.

[12] Id.

[13] Consumer Complaint Form, Miss. Ins. Dept., http://www.mid.ms.gov/consumers/pdf/consumer-complaint-company.pdf (last visited Nov. 27, 2016).

[14] 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).

[15] File Company Complaint, Miss. Ins. Dept., http://www.mid.ms.gov/consumers/file-company-complaint.aspx (last visited Nov. 27, 2016).

[16] Id.

[17] Id.

[18] Id.