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 documents that your insurer sent 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.
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 whether to approve a treatment or pay a claim.
In South Carolina, you can request a standard external review if you meet all of the following qualifications:
- Your insurer denied, reduced, or terminated your requested service because it (1) did not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or (2) it was experiment or investigational and involves a life-threatening or seriously disabling condition; and
- Your insurer is required to pay at least $500 for the requested treatment or service; and
- You have completed the internal appeals process or meet an exception for this requirement.
You can request an external review before completing the internal appeals process if you have not yet received your requested service and one of the following applies:
- Your treating physician has certified in writing that you have a serious medical condition (if this is the case, you also qualify for an expedited external review);
- Your requested service is experimental or investigational and your treating physician has provided you with required certifications;
- Your insurer has not provided you with a written decision within the timeframe required for the internal appeals process even though you provided your insurer with all of the requested information; or
- Your insurer waived the internal appeals process.
In certain circumstances, you can request an expedited external review, which means you do not need to finish the internal appeals process and the independent review organization must provide you with a decision within three business days. You should consult with your insurer to determine whether you can skip the internal review process altogether. You can request an expedited external review in the following circumstances:
- Your treating physician has certified in writing that you have a serious medical condition; or
- You received emergency medical care, have not been discharged from a facility, and may be held financially responsible for the emergency medical care.
How do I request an external review?
You must submit a written request for a standard external review to your health insurer within 60 days from the date of the insurer’s final decision and within 15 days if you are requesting an expedited external review. Your health insurer should have sent you information on how to submit the external review request when it denied your internal appeal.
You should include the following documents with your request:
- A signed medical record release form (Appendix B of the Patient’s Guide to External Review); and
- Any new information and documentation that you did not include with your previous request for an internal appeal.
If your insurer denied your claim because the requested treatment or service was considered experimental or investigational, you must include a letter or certificate from your physician. The requirements for physician’s certification are included on page 7 of the Patient’s Guide to External Review.
Independent Review Organization’s Duties
Once your health insurer receives your external review request, it will assign your request to an independent review organization (“IRO”), send the IRO copies of all documents and information it relied upon in denying your request, and send you notice of these actions. The IRO will contact you within five days of receipt of the external review request if it needs additional documents or information. You will have seven business days to provide them with the requested information.
How long will the external review process take?
The external review process should take no more than 45 days once the IRO receives your request and documentation from your insurer. If you requested an expedited external review, the process should take no longer than three business days after your request is received.
How do I file a complaint?
If you are a South Carolina resident and your claim is denied after the external review process, you can file a complaint with the Consumer Services Division of the South Carolina Department of Insurance (“Division”).
Your complaint should include the following information:
- The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
- The name and email address of the insured individual, if different than the Complainant;
- The name and telephone number of insurance company;
- The name and telephone number of the insurance adjuster or agent, if applicable;
- The policy number, claim number, identification number, and date of loss;
- The name of your employer, if applicable;
- The type of insurance;
- The reason for the complaint; and
- The details of the complaint.
You should submit the following supporting documents with your complaint:
- A copy of your insurance card;
- Copies of the determination letters 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 doctor;
- A copy of your insurance policy; and
- All responses from your insurer.
Consumer Services Division
P.O. Box 100105
Columbia, SC 29202-3105
What happens after the Consumer Services Division receives my complaint?
Once the Division receives your complaint, it will forward a copy of your complaint to your health insurer for a response. Your insurer has ten days to respond. The Division will evaluate your case to determine whether your insurer violated any laws. If it did, the Division will refer the matter to the Investigative Division. The Division will notify you if it refers your case or if a decision is reached. The Division may require your health insurer to comply with your health policy and may also fine the insurer or issue it a citation.
Who should I call if I have any questions about filing a complaint?
You can contact the Department at (803) 737-6180 or (800) 768-3467. The Department is open from 8:00 a.m. to 6:00 p.m. Monday through Thursday and 8:00 a.m. to 5:00 p.m. on 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. 26, 2016).
 Appealing a Health Plan Decision: Internal Appeals, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Nov. 26, 2016).
 Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 26, 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).