My insurer refuses to cover my prescribed treatment. What can I do?
Appeal the decision;
Request an external independent 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.
- 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 expedited or urgent internal appeal, if applicable. You can file an expedited internal appeal (also referred to as an “urgent” internal appeal) if your situation is urgent. Your situation is urgent if a 30 to 60 day delay in receiving the prescribed treatment could seriously jeopardize your life, health, or ability to regain function or subject you to severe and intolerable pain. You can also file an expedited appeal if you have an issue related to admission, availability of care, continued stay, or health care services received on an emergency basis and you have not yet been discharged from the facility. You can call your health insurer directly to request an expedited internal appeal.
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. An expedited internal appeal should take no longer than 72 hours.
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 Washington law, you are entitled to request an external review in the following circumstances:
- If your insurer denies your coverage after an internal appeal; or
- If your insurer does not meet the required timeframes for providing you with a decision on the internal appeal.
You can also request an expedited external appeal if your medical situation is urgent and waiting would jeopardize your life, health, or ability to function and you requested an expedited internal appeal.
You should submit your request for an external review to your health insurer within 60 days from the date that your insurer sent you the final decision. You can find a sample letter for requesting an external review on page 29 of this document. You should include any new information and documentation that you did not previously include with your request for an internal appeal.
Your health insurer will assign an independent review organization to review your appeal and send you notice of which review organization is handling your case and the organization’s contact information.
The external review process should take no more than 20 days after the external review organization receives the request for fully-insured plans and no more than 45 days for self-insured plans. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.
If you are a Washington resident and your claim is denied after the external review process, you can file a complaint with the Washington Office of the Insurance Commissioner (“Office”).
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, address, email address, and telephone number of the insured individual, if different than the Complainant;
- The name of insurance company;
- Policy number, claim number, type of policy, and type of insurance;
- The name, company name, address, and telephone number of the insurance adjuster;
- Type of problem;
- The details of the complaint; and
- What you consider to be a fair resolution.
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 may be submitted online here, faxed to (360) 586-2018, or mailed to the following address:
The Office will forward a copy of your complaint to your health insurer and request a response. It takes approximately 30 days from the time your complaint is filed to receive a response from the insurer. The Office will then review the insurer’s response and provide you with an explanation of the health insurer’s response and the Office’s review. The Office may force the insurance company to comply with the policy, issue a citation, or fine the company.
You can contact the Washington Office of the Insurance Commissioner at (800) 562-6900. The Office is open from 8:00 a.m. to 5:00 p.m. Monday through Friday. For more information about the internal appeal or external review process, the Office provides a guide to appealing your health care treatment denial, which you can find here.