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:

  1. Request a grievance review;

  2. Request an external review; and

  3. File a complaint.

How do I request a grievance review?

If your insurer denies your claim, you can request a reconsideration of its decision.[1] Your insurer should provide you with a reconsideration decision within one business day.[2]

If the insurer denies your claim after the reconsideration process, you have the right to a first and possibly a second level grievance review, also referred to as an internal appeal.[3] This means you can ask your insurer to conduct a full and fair review of its decision. To request a first level grievance review, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter telling you 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 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 to file the grievance, 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 grievance process. Someone in his or her office might help you fill out the forms to request a grievance and draft a strong grievance letter.
  • Submit the grievance request. You or someone in your health care provider’s office should submit the grievance 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.
  • Request an expedited review, if applicable. You can request an expedited review of your case if waiting 55 to 110 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function.[4] You can submit your request for expedited review by phone or in writing.[5]
  • 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 grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

Group Health Plans. If you have a group health plan and your insurer denies your claim after the first level grievance review, you can request second level grievance review.[6] Your insurer must notify you of the procedure to request a second level grievance review with its decision on the first level grievance.[7] An advisory panel consisting of members who were not involved in the first level grievance will conduct the second level grievance.[8]

Individual Plans. If you have an individual plan, review your policy to determine whether you are limited to the first level of grievance or if you have the option to request a second level of grievance.[9]

How long should the internal grievances process take?

A first level internal grievance should take no more than 55 days to complete.[10] A second level grievance should also take no more than an additional 55 days to complete.[11] An expedited grievance request should take no more than 72 hours from when the insurer receives your request.[12]

What if my insurer denies my coverage after an internal grievance?

If your insurer denies your coverage after the grievance process, you are entitled by law to request an external review from an independent third party, which means your insurer no longer has the final say over whether to approve a treatment or pay a claim.

You may request an external review if your insurer denies your claim during the grievance process for one of the following reasons:

  • The treatment is deemed not medically necessary;
  • The treatment is experimental;
  • The treatment is not as effective as other treatments; or
  • You require a different or lesser level of care.[13]

You can request an expedited external review if your medical situation is urgent and waiting the 45 days it would take to complete a standard external review would jeopardize your life or ability to function.[14]

How do I request an external review?

You should contact the Missouri Department of Insurance (“Department”) to request an external review of your case. There is currently no deadline under Missouri law within which to file your request for an external review.[15]

You can reach the Department by telephone at (573) 751-4126 or by mail at the following address:

Missouri Department of Insurance
Truman State Office Building
Room 530
P.O. Box 690
Jefferson City, MO 65102[16]

The Department will then contact your health insurer to obtain copies of all documents in the insurer’s claims file and determine whether your case is eligible for external review.[17] Once the Department determines that your case is eligible for external review, a representative will contact both you and your health insurer, and you will have 15 business days to provide any additional medical information that you would like the external review organization to consider in its review.[18]

How long will the external review process take?

The external review process should take no more than 45 calendar days from the date the external review organization receives your information.[19] If you request an expedited external review, the process should take no longer than 72 hours from when the external review organization receives all medical information related to your claim.[20]

How do I file a complaint?

If your insurer still denies your coverage 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, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The name and address of insurance company;
  • The employer name, if a group policy;
  • Group or certificate number, policy or identification number, effective date, claim number, and date of loss;
  • The reason for the complaint; and
  • The details of the complaint.[21]

Supporting documents. You should also 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 grievances and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[22]

How to submit. The complaint may be submitted online here, faxed to (573) 526-4898, or mailed to the following address:[23]

Missouri Department of Insurance
P.O. Box 690
Jefferson City, MO 65102-0690

What happens after the Department receives my complaint?

Once the Department receives your complaint, it will send you written confirmation and the tracking number for your complaint.[24] The Department will forward a copy of your complaint to your health insurer and request a response.[25]  Your insurer will have 20 days to respond to the complaint.[26] If the Department determines that a law or regulation has been violated, the Department will direct the health insurer to either reprocess any claims in or request other corrective action.[27]

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

You can contact the Department at (800) 726-7390. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.