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 take the following steps within 180 days of receiving notification from your insurer of its decision to deny your claim:
- 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.
- Request an expedited internal appeal, if applicable. If you need urgent care, as determined by your health care provider, you should contact your insurer and ask for instructions on how to request an expedited internal appeal.
- 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?
Your insurer should provide you with a notice of its decision to deny or grant your claim within the following timeframes:
- 30 days if you have not yet received the requested service or treatment;
- 60 days if you have received the service or treatment but are waiting for reimbursement;
- 72 hours if you have requested an expedited internal appeal; and
- 24 hours if you are receiving treatment and your health insurer seeks to reduce or stop your benefits.
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. Under Montana law, you are entitled to request an external review if your insurer has:
- Denied your internal appeal because it determined that the service or treatment was experimental, investigational, or not medically necessary; or
- Rescinded your policy.
You can request an expedited external review if you need urgent medical care, as determined by your health care provider. If your case is urgent, you must first request an expedited internal review, as discussed above. If your health insurer decides to deny your internal appeal, it must notify you immediately and send your case directly to an independent review organization for review.
How do I request an external review?
You should file your request for a standard external review with your health insurer within four months from the date your insurer sent you the final decision. You can request assistance from the Montana Department of Insurance (“Department”) with filing your request. You can reach the Department at (800) 332-6148 or (406) 444-2040.
Your health insurer must determine whether your claim is eligible for an external review within five days of receiving your request and must provide all information related to your request to an external review organization within an additional five days.
After your insurer notifies you that your claim has been assigned to an independent review organization, you will have ten business days to provide any new information and documentation that you had not previously included with your request for an internal appeal to the independent review organization.
How long will the external review process take?
The external review process should take no more than 45 days from when the external review organization receives your request from your health insurer. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.
How do I file a complaint?
If you are a Montana resident and you still lack coverage after the external review process, you can file a complaint with the Department.
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 names of other parties involved in the claim;
- The name of insurance company, agency, and/or agent, adjuster, or appraiser, if applicable;
- Policy number, certificate number, claim number, date of loss or service;
- The reason for the complaint; and
- The details of the complaint.
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 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
Commissioner of Securities and Insurance
Montana Department of Insurance
840 Helena Avenue
Helena, MT 59601
What happens after the Department receives my complaint?
Once your complaint is filed, you will receive confirmation and an assigned file number. A copy of the complaint will be sent to your health insurer who must then provide a response within 21 days. A compliance specialist will then review your complaint and the insurance company’s response. If the specialist determines that a law has been violated or the health insurer is not abiding by the insurance policy, the Commissioner of Securities and Insurance will request that the health insurer take corrective action. The complaint process may take up to 90 days.
Who should I call if I have any questions about filing a complaint?
You can contact the Montana Department of Insurance at (800) 332-6148 or (406) 444-2040 (in Helena). 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).
 How it Works: The Internal Appeal Process, Mont. Comm’r of Sec. & Ins., http://csimt.gov/wp-content/uploads/HowitWorks_InternalAppealsv2-1.pdf (last visited Nov. 27, 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).
 How it Works: The External Review Process, Mont. Comm’r of Sec. & Ins., http://csimt.gov/wp-content/uploads/HowitWorks_InternalAppealsv2-1.pdf (last visited Nov. 27, 2016).
 Consumer Complaint, Mont. Comm’r of Sec. & Ins., https://sbs.naic.org/solar-web/pages/public/onlineComplaintForm/onlineComplaintForm.jsf?state=MT&dswid=-4344 (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 Compliant, Mont. Comm’r of Sec. & Ins., Mont. Comm’r of Sec. & Ins., https://sbs.naic.org/solar-web/pages/public/onlineComplaintForm/onlineComplaintForm.jsf?state=MT&dswid=-4344 (last visited Nov. 27, 2016).