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. 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 unless you and your insurance company agree to a longer time period.
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 an external review if your insurer denies your coverage after an internal appeal. You are entitled to expedited external review if your medical situation is urgent and waiting 30 days for the requested treatment would jeopardize your life or ability to function.
How do I request an external review?
You should send your request for an external review to the Governor’s Office for Consumer Health Assistance (“Governor’s Office”) within four months from when your insurer sent you the final decision. The Governor’s Office will then assign an external review organization to review your claim.
You can find a copy of the external review request form here. You should include the following information with your request:
- Name of applicant;
- Name, address, and telephone number of the insured person;
- Name of the patient (if different from the applicant);
- Name, address, and telephone number of the health insurer;
- Insurance identification number, claim or reference number;
- Employer name and telephone number;
- Name and address of your treating physician or health care provider;
- The name and telephone number of the contact person at your provider’s office;
- Your medical record number;
- The reason for denial;
- Brief description of the claim;
- Description of the health care service or treatment in dispute; and
- The health care provider certification form on page 6 of the external review packet (this form only needs to be completed if you are requesting an expedited review).
You should include the following documents with your request:
- A copy of your insurance card or other evidence showing coverage;
- A copy of the determination letter from your health insurer;
- A copy of your insurance policy; and
- Any new information or documentation not included with your request for an internal appeal.
Submitting a standard external review
If you are requesting a standard external review, you should submit your request to the following address:
Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas, NV 89101
Submitting an expedited review
If you are requesting an expedited external review, you should contact the Office for Consumer Health Assistance at (702) 486-3587 or (888) 333-1597 for instructions on the fastest way to submit your request and supporting documentation.
How long will the external review process take?
The external review process should take no longer than 15 days. If you requested an expedited external review, the Office for Consumer Health Assistance will let you know within 72 hours whether your claim is eligible for an expedited review. If your claim is eligible, you should receive a decision within four days.
How do I file a complaint?
If you are a Nevada resident and you think your insurer has done something illegal or unethical, you can file a complaint with the Nevada Division of Insurance (“Division”).
You can find a copy of 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 (“Complainant”);
- The name of the insured individual, if different than the Complainant;
- The name of insurance company;
- Policy number, claim number, date of loss/incident, if applicable;
- The details of the complaint; and
- What you consider to be a fair resolution.
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.
How to submit
The complaint may be submitted online here or mailed to one of the following addresses, whichever is closest to you:
Nevada Division of Insurance
1818 E. College Pkwy. #103
Carson City, NV 89706
— or —
Nevada Division of Insurance
2501 E. Sahara Ave. #302
Las Vegas, NV 89104
What happens after the Division receives my complaint?
Your health insurer should respond to your complaint within 28 calendar days. If you have not heard from the Division within 30 days, you should contact the Division to follow up. The Department will investigate your claim and can require the health insurer to comply with the policy or issue a citation or fine for any violations.
Who should I call if I have any questions about filing a complaint?
You can contact the Nevada Division of Insurance at (775) 687-0700 (Carson City office), (702) 486-4009 (Las Vegas office) or toll-free at (888) 872-3234. The Department is open from 8:00 a.m. to 5:00 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. 27, 2016).
 Nev. Rev. Stat. § 695G.210 (2016).
 Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 27, 2016).
 Nev. Rev. Stat. § 695G.245 (2016).
 External Review Request Form, Nev. Div. of Ins., http://dhhs.nv.gov/uploadedFiles/dhhsnvgov/content/Programs/CHA/Ex_R/Nevada%20External%20Review%20 Application.pdf (last visited Nov. 27, 2016).
 Nev. Rev. Stat. § 695G.261 (2016).
 Nev. Rev. Stat. § 695G.271 (2016).
 Consumer Complaint Form, Nev. Div. of Ins., http://doi.nv.gov/uploadedFiles/doinvgov/_public-documents/Consumers/ComplaintFormA.pdf (last visited Nov. 27, 2016).
 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).
 Consumer Complaint Form, http://doi.nv.gov/uploadedFiles/doinvgov/_public-documents/Consumers/ComplaintFormA.pdf (last visited Nov. 27, 2016).