Virginia

 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.
  • Request an urgent care appeal, if applicable. You can request an urgent care appeal if you require urgent care.[2] You require urgent care if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function or you would be in severe pain that could not be adequately managed without the requested service or treatment.[3] You can submit your request for an urgent care appeal either over the phone or in writing to your health insurer.[4]

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.[5] If you have requested an urgent care appeal, the process should take no more than 72 hours to complete, unless there is vital information missing.[6]

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Virginia law, you are entitled to request an external review in the following circumstances:

  • If your insurer denies your coverage after an internal appeal; or
  • Your insurer has not responded to your internal appeal request within the required 30 or 60 day timeframes and you have not agreed to extend or waive the time.[8]

You can also request an expedited external review if your medical situation is urgent. You can file a request for an expedited external review while you file a request for an urgent care appeal.[9]

How do I request an external review?

You should submit your request for an external review to the Virginia Bureau of Insurance (“Bureau”) within 120 days from the date that your insurer sent you the final decision.[10]

Information

You can find a copy of the request Form 216-A here. You should include the following information with your request:

  • The name of the applicant;
  • The name, address, email address, telephone number, and date of birth of the covered person;
  • The name, address, and telephone number of the insurance company;
  • Insurance identification number and insurance claim or reference number;
  • Your employer’s name and telephone number;
  • The name and address of your treating health care provider;
  • The name and telephone number of the contact person at your health care provider’s office; and
  • The reason for the denial.[11]

If you are requested an expedited external review, your health care provider must complete a Form 216-C “Physician Certification Expedited External Review Request” certifying that a delay in treatment of your condition would seriously jeopardize your life, health, or ability to regain function. A copy of the Form 216-C can be found here. If your claim involves emergency services and you have not yet been discharged from an inpatient facility (such as a hospital), you do not need to complete Form 216-C.[12]

Supporting document

You should include the following documents with your request:

  • A signed medical records release form (included in request packet);
  • A copy of your insurance card;
  • A copy of the final determination letter from your insurance company; and
  • Any additional or new information and documentation not included with your request for an internal appeal.[13]

Submitting an external review

You can submit your request by fax to (804) 371-9915, by email to externalreview@scc.virginia.gov, or by mail to the following address:

State Corporation Commission
Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218[14]

How long will the external review process take?

The independent external review organization should provide a decision within 45 days of receipt of the request for external review.[15] The entire external review process should take no more than 60 days.[16] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[17]

How do I file a complaint?

If you are a Virginia resident and have completed the internal and external review processes, you can file a complaint with the Bureau.

Complaint information

Your complaint should include the following information:

  • The type of insurance;
  • The name, address, email address, and telephone number of the patient;
  • The name, address, email address, telephone number, and relationship to patient of the person filing the complaint (“Complainant”);
  • The name of the insurance company;
  • Policy number, certificate number, or identification number; and
  • A description of the issue.

Supporting documents

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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[18]

How to submit

The complaint may be submitted by fax to (804) 371-9944, or by mail to the following address:

State Corporation Commission
Bureau of Insurance
Life and Health Division
P.O. Box 1157
Richmond, VA 23218[19]

What happens after the Bureau receives my complaint?

The Bureau will send a copy of the complaint to your health insurer and attempt to resolve the issue with them.[20] It may take up to 45 days or longer for your claim to be resolved, depending on the complexity of the issue.[21] The Bureau may require the insurance company to comply with the policy (in other words, make the insurer cover the requested treatment or service), issue a citation, or fine the company.

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

You can contact the Virginia Bureau of Insurance at (804) 371-9691, (800) 552-7945 (in-state), or (877) 310-6560. The Bureau is open from 8:15 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. 26, 2016).

[2] 14 Va. Admin. Code § C5-216-50 (2016).

[3] 14 Va. Admin. Code § C5-216-20 (2016).

[4] 14 Va. Admin. Code § C5-216-50 (2016).

[5] Appealing a Health Plan Decision: Internal Appeals, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/(last visited Nov. 26, 2016).

[6] 14 Va. Admin. Code § C5-216-50 (2016).

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

[8] http://www.scc.virginia.gov/boi/omb/ext_review.aspx# (last visited Nov. 26, 2016)

[9] Va. Code Ann. § 38.2-3559 (2016).

[10] Id.

[11] External Review Request Form, http://www.scc.virginia.gov/boi/omb/files/216a.pdf (last updated July 2011).

[12] Id.

[13] Id.

[14] Id.

[15] Va. Code Ann. § 38.2-3561 (2016).

[16] Id.

[17] Va. Code Ann. § 38.2-3562 (2016).

[18] 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).

[19] http://www.scc.virginia.gov/publicforms/262/lhinquiry.pdf

[20] Id.

[21] http://www.scc.virginia.gov/boi/complaint.aspx#A7