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 independent medical review; and
- File a complaint.
Appeal the Decision
How do I appeal the decision?
If your insurer denies your claim, you have the right to an internal appeal.[1] 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 30 days of receiving the denial letter from your insurer:
- 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 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. You should ask them to write a letter of medical necessity.
- 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 your case is urgent, you should contact your insurer and ask for instructions on how to apply for an expedited internal appeal. Your situation is urgent if waiting 30 days would seriously jeopardize your health, life, or ability to regain function.
- 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 decision on the appeal within 30 days if you are requesting prior authorization, within 60 days if you already received medical services but are waiting for reimbursement, and within 72 hours if your case is urgent.[2]
In which circumstances can I apply for an independent medical review?
During an independent medical review (also referred to as an “external review”), an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under California law, you are entitled to request an independent medical review in the following circumstances:
- You filed an internal appeal but your insurer failed to provide you with a decision within the allotted timeframe; or
- Your insurer denied your claim after you filed an internal appeal because it determined that your requested treatment was medically unnecessary, experimental, or investigational.[4]
You can request an expedited independent medical review at the same time that you request an expedited internal appeal in urgent situations.[5]
Independent Medical Review
How do I request an independent medical review?
You must submit a request for an independent medical review within six months of receiving the last determination letter from your insurer. This deadline may be shorter if you are insured through your employer and the plan is “self-insured.” You should check with your employer for more information.
You must determine where to file your independent medical review. This determination depends on what type of plan you have.
HMOs, PPOs, and Specialized Plans.
The California Department of Managed Healthcare (“DMHC”) regulates all health maintenance organizations (HMOs), some preferred provider organization (PPO) plans, as well as specialized plans that cover only certain kinds of care, such as certain dental and vision care plans, behavioral or mental health plans, and chiropractic plans.[6] If you need help figuring out if DMHC regulates your plan, you should visit www.hmohelp.ca.gov or call DMHC at 1-888-466-2219.
If your plan is regulated by the DMHC, you should submit a request for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (916) 255-5241 or mail it to:
Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725[7]
Fee-for-service plans and PPOs.
The California Department of Insurance (“CDI”) regulates indemnity health insurance plans, also known as fee-for-service plans, and most PPO plans.[8] You can call the CDI at 1-800-927-4357 to find out whether it regulates your specific plan.
If your plan is regulated by the CDI, you should apply for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (213) 897-9641 or mail it to:
Department of Insurance, Health Claims Bureau
300 S. Spring Street, South Tower
Los Angeles, CA 90013
Self-funded plans.
If you receive your health insurance through your employer, check with your employer to see if your plan is “self-funded.” Neither DMHC nor CDI regulate these types of plans. If your plan is a self-funded employer plan, ask your employer to provide you with the contact information for the plan’s administrator to find out what your independent review options are.
Expedited independent medical review requests.
If you seek an expedited independent medical review, ask your health care provider to certify, in writing, that a delay in receiving the requested treatment or service would create a serious and imminent risk to your health.[9]
Insurer’s responsibility.
If your request for an independent medical review is granted, your health insurer has 24 hours to provide the necessary documentation and information to the independent medical reviewer.[10]
How long will the independent medical review process take?
If DMHC is overseeing your independent medical review, the process should take no more than 30 days. If the review is urgent, the process should take no more than seven days after your case has qualified for an independent medical review and the required documents have been received.[11]
If the CDI is overseeing your case, the independent medical review process should take no more than 45 days. If you request an expedited independent review, the process should take no longer than three days after the independent medical reviewer receives your request.[12]
Filing a Complaint
How do I file a complaint?
If you are a California resident and your insurer denies your coverage after the independent medical review process, you can file a complaint with the DMHC.[13]
Complaint information.
You can obtain a copy of the complaint form here. Your complaint should include the following information:
- The name and date of birth of the patient;
- The name, address, telephone number, and email address of the parent or guardian, if filing on behalf of a minor child;
- The name of insurance company;
- The patient’s membership number, medical group name, and name of employer;
- The type of complaint (g., authorization of future services);
- The patient’s medical condition or diagnosis;
- The treatment, services, or medications being requested;
- The name and telephone number of the patient’s primary care provider; and
- Brief description of the problem (g., denied treatment, unpaid claim).[14]
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 independent medical 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.[15]
Submitting the Complaint
You can submit the complaint and supporting documents online here, fax them to (916) 255-5241, or mail them to:
Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725[16]
What happens after the Department receives my complaint?
Once you submit your complaint, an analyst, a nurse consultant, or a lawyer will review it and make a decision. That person may examine your account, records, documents, and transactions. He or she may question witnesses, request additional documents from other parties, and hold a hearing.[17] The Department will then send you and your insurance plan notice of its decision.[18]
Who should I call if I have any questions about filing a complaint?
You can contact the California Department of Managed Health Care Help Center at (888) 466-2219. The help center is available from 8:00 a.m. to 6:00 p.m. Monday through Friday.
References
[1] https://www.healthcare.gov/appeal-insurance-company-decision/appeals/
[3] https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
[4] https://www.insurance.ca.gov/01-consumers/110-health/60-resources/01-imr/index.cfm#request; https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReview(IMR).aspx#.WCONw_krLb1
[5] https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
[6] https://www.insurance.ca.gov/01-consumers/110-health/60-resources/01-imr/index.cfm
[7]https://www.dmhc.ca.gov/HealthCareinCalifornia/TypesofPlans.aspx#.WCo8afkrLb0
[9]http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20H/PDF%20HIMURegulatoryOversight.pdf
[10] Cal. Ins. Code § 10169.3 (2016)
[11]http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaint.aspx#.WCNu8vorI2w
[12] https://www.insurance.ca.gov/01-consumers/110-health/60-resources/01-imr/index.cfm
[13] If your health plan isn’t covered by the Department of Managed Health Care, the Department will assist you in contacting the Department of Insurance.
[14] State of California, Department of Managed Health Care, http://www.dmhc.ca.gov/File-a-Complaint/Apply-for-an-Independent-Medical-Review-IMR/IMR-Application-Form.aspx#.WAZPLYWcHD4, last visited Oct. 18, 2016.
[15] Complaint to Federal Government Agency: Patient, Legal Action Center, https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx, last visited Oct. 17, 2016.
[16] State of California, Department of Managed Health Care, http://www.dmhc.ca.gov/File-a-Complaint/Apply-for-an-Independent-Medical-Review-IMR/IMR-Application-Form.aspx#.WAZPLYWcHD4, last visited Oct. 18, 2016.
[17] Cal. Gov’t Code § 1346 (2016).
[18] State of California, Department of Managed Health Care, http://www.dmhc.ca.gov/FileaComplaint/FrequentlyAskedQuestions.aspx#legal, last visited Oct. 18, 2016.
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