Washington, D.C.

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 appeal?

If your insurer denies your claim, you have the right to file an appeal with your health insurer.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file an 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 file an appeal.
  • 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 appeal process. Someone in his or her office might help you fill out the forms to file 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.
  • Ask for an expedited review, if applicable. You can request an expedited internal review from your insurer if the internal appeal is from a decision regarding urgent or emergency medical conditions.[2] You have the right to continued coverage at the level of benefits provided prior to the reduction, termination, or limitation pending the outcome of an expedited appeal.[3] Your insurer should have provided you with its requirements for requesting an expedited internal appeal process with your initial determination letter.[4] Be sure to follow those instructions.
  • 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 requested service or treatment but are waiting for reimbursement.[5] The process should take a maximum of 24 hours if the internal appeal involves an urgent or emergency medical condition.[6]

In what 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 District of Columbia law, you are entitled to request an external review in the following circumstances:

  • Your insurer denies your coverage after an internal appeal within the allotted timeframe;
  • The insurer waives the requirement that the internal appeals process be completed before proceeding to external review; or
  • The insurer does not comply with the deadlines and requirements of the internal appeals process.[8]

You can request an expedited external review if you have an urgent or emergency medical condition. If you believe you qualify for an expedited external review, you can apply for one at the same time that you apply for an expedited internal appeal.

How do I request an external review?

You must file your request for an external review with the District of Columbia Office of Health Care Ombudsman and Bill of Rights within four months of the date on your insurer’s most recent decision.

Information

You can find a copy of the external review request form here:[9] You should include the following information:

  • The name of the person requesting review;
  • The name of the insurance company;
  • A description of the review requested;
  • The patient’s name, date of birth, gender, address, telephone number, and email address;
  • The patient’s diagnosis and procedures performed;
  • The name, address, and telephone number of the referring physician;
  • The name, address, and telephone number of the treating facility;
  • The name and address of the insurance company;
  • Member identification number;
  • Date of final decision; and,
  • Basis for the appeal.[10]

Supporting documents

You should also include the following supporting documents with your application:

  • A copy of all determination letters from your health insurer;
  • A signed medical records release form here; and
  • Any medical records, health care provider statements, and other information for the external review agency to consider.[11]

How to submit an external review request

You can submit your request and supporting documents by fax to (202) 478-1397 or by mail to the following address:[12]

Government of the District of Columbia
Office of Health Care Ombudsman and Bill of Rights
One Judiciary Square
441 4th Street, NW, Suite 900S
Washington, DC 20001

Questions

If you have questions regarding the process, you can contact the Office of Health Care Ombudsman and Bill of Rights at (877) 685-6391.

How long will the external review process take?

The external review process should take a maximum of 45 calendar days to complete.[13] An expedited external review should be completed within 72 hours.[14]

How do I file a complaint?

If you are a resident of the District of Columbia and your claim is denied after the external review process, you can file a complaint with the Department of Insurance, Securities and Banking (“Department”).

Complaint information

You can find 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, address, telephone number, and email address of insurance company;
  • The type of problem;
  • Policy number;
  • Name, title, and telephone number of contact at insurance company, dates you contacted them, and their response;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[15]

Supporting documents

You should submit the following supporting documents with your request:

  • 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.[16]

How to submit

You can submit your complaint and the supporting documents online here, by faxing them to (202) 354-1085, by emailing them to disbcomplaints@dc.gov, or by mail or hand delivered to the following address:

District of Columbia Department of Insurance, Securities, and Banking
Attn: Consumer Services Division
810 First Street, NE, Suite 701
Washington, DC 20002[17]

What happens after the Department receives my complaint?

The Department will look into your complaint to see if any District laws or procedures have been violated.[18] A representative will contact your insurance company to obtain information and an explanation from the insurer.[19] Most complaints are investigated and resolved within 45 days.[20]

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

If you have questions regarding filing a complaint, you can contact the Department at 202-727-8000 or you can email them at disb.complaints@dc.gov. The Department is open from 8:15 a.m. to 4:45 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/.

[2] D.C. Code Ann. § 44-301.06 (2016).

[3] D.C. Code Ann. § 44-301.04 (2016).

[4] Id.

[5] D.C. Code Ann. § 44-301.06 (2016).

[6] Id.

[7] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Dec. 13, 2016).

[8] D.C. Code Ann. § 44-301.07 (2016).

[9] Appeal Form, healthcareombudsman.dc.gov, http://healthcareombudsman.dc.gov/node/912532 (last updated Feb. 20, 2014).

[10] Id.

[11] D.C. Code Ann. § 44-301.07 (2016).

[12] Appeal Form, healthcareombudsman.dc.gov, http://healthcareombudsman.dc.gov/node/912532 (last updated Feb. 20, 2014).

[13] D.C. Code Ann. § 44-301.07 (2016).

[14] Id.

[15] Consumer Complaint Form – DISB, D.C. Dept. of Ins., Sec., & Banking, http://dcforms.dc.gov/webform/consumer-complaint-form-disb-0 (last visited Dec. 13, 2106).

[16] 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).

[17] Consumer Complaint Form – DISB, D.C. Dept. of Ins., Sec., & Banking, http://dcforms.dc.gov/webform/consumer-complaint-form-disb-0.

[18] File a Complaint or Report Fraud, D.C. Dept. of Ins., Sec., & Banking, http://disb.dc.gov/service/file-complaint-or-report-fraud.

[19] Id.

[20] Id.