My insurer refuses to cover my prescribed treatment. What can I do?
Appeal the decision;
Request an external review; and
File a complaint.
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 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.
- Request an expedited internal review, if applicable. You can request an expedited internal appeal if a 30 to 60 day delay in treatment would seriously jeopardize your health, life, or ability to regain function or if you experience pain that cannot be adequately treated. You should contact your health insurer 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.
- Determine if a second level appeal is needed. If your insurer denies your appeal, it may require you to request a second level appeal. Your insurance policy should include information regarding whether your health insurer offers one or two levels of internal appeals. If it is unclear, contact your insurer for more information. However, insurers cannot require that you exhaust two levels of internal appeals prior to requesting an external review.
For individual and non-employer group coverage plans, the internal appeals process should take no more than 30 days from the time the health insurer receives all information necessary to review the appeal.
For employer group coverage plans, the internal appeals process should take no longer than 30 days from the time the health insurer receives all information for each level of appeal, for a total of 60 days if two levels of appeal are required.
You should receive a decision on an expedited internal appeal within 72 hours of your insurer receiving your request.
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 Ohio law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal or does not provide you with a decision within the required timeframe.
You can also request an expedited external review if your situation is urgent. You can request an expedited external review at the same time that you requested an expedited internal appeal.
You should submit your request for an external review to your health insurer in writing by mail, fax, or email. You should include any new information and documentation that you did not previously include with your request for an internal appeal. Please sure to note in your request whether you are seeking a standard external review or an expedited external review. You must file your request within 180 days from the date that your insurer sent you the final decision.
If your claim involves a question about your insurance policy but does not involve a medical determination or any medical information, your insurer will send your request to the Ohio Department of Insurance who will conduct the review of your claim. Otherwise, your insurer will send your request to an external review organization.
The external review process should take no more than 30 days from the date the external review organization receives your request. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.
If you are an Ohio resident and your insurer still denies your claim after the external review processes, 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 of insurance company;
- Group number, policy number, and claim number;
- The name, address, email address, and telephone number of the insurance agent;
- The details of the complaint;
- What you consider to be a fair resolution; and
- The reason for the complaint.
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 health care provider;
- A copy of your insurance policy; and
- All responses from your insurer.
How to submit. The complaint and supporting documents may be submitted online here or mailed to the following address:
Ohio Department of Insurance
Consumer Services Division
50 West Town Street, Third Floor, Suite 300
Columbus, OH 43215
You should hear from the Department within two weeks with confirmation that it has received your complaint. The confirmation letter will provide you with the name of the analyst handling your complaint, what action the Department plans to take, and how long the process will take. The Department can force your health insurer to comply with the policy and either pay your claim or cover the requested treatment or service or issue a citation or fine the company.
You can contact the Ohio Department of Insurance at (800) 686-1526. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.