External Review FAQs

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 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.[2] 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.[3] You can call your health insurer directly to request an expedited internal appeal.[4]

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.[5] An expedited internal appeal should take no longer than 72 hours.[6]

During an external review, an independent third party reviews your insurer’s decision.[7] 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.[8]

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.[9]

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.[10] You can find a sample letter for requesting an external review on page 29 of this document.[11] 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.[12]

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.[13] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[14]

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.[15]

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.[16]

How to submit. The complaint may be submitted online here, faxed to (360) 586-2018, or mailed to the following address:

Washington State Office of the Insurance Commissioner
P.O. Box 40255
Olympia, WA 98504-0255[17]

The Office will forward a copy of your complaint to your health insurer and request a response.[18] It takes approximately 30 days from the time your complaint is filed to receive a response from the insurer.[19] 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.[20] 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.

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 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 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.

The internal appeals process should take a maximum of 30 days.[2]

During 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 Oregon law, you are entitled to request an external review in the following circumstances:

  • If your insurer denies your coverage after an internal appeal because it determined that the requested treatment or service were medically unnecessary, experimental/investigational;
  • You are trying to avoid a disruption in your care; or
  • You are disputing the appropriate setting for treatment or the appropriate level of care; or
  • Your health insurer rescinded or ended your coverage.[4]

You can request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or health.[5] You should request the expedited external review at the same time that you request the internal appeal.

You should submit your request for external review to your health insurer, which will forward your request to the Division of Financial Regulation (“Division”).[6] The Division will then randomly assign your case to an external review organization.[7]

You must file your request within 180 days from the date that your insurer sent you the final decision.[8] You should include any additional information and documentation that you did not include with your previous request for an internal appeal with your request for an external review, including medical records and recommendations of your treating health care provider or providers.[9] Be sure to note on your application whether you are requesting a standard or expedited external review.

The external review process should take no more than 30 days after you apply to the insurance company for external review.[10] If you requested an expedited external review, the process should take no more than three days after your request is received.[11]

If you are an Oregon resident and your claim is denied after the external review process, you can file a complaint with the Division.

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 names of other parties involved in the claim;
  • The name of insurance company;
  • The policy number, claim number, and date of loss;
  • The reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[12]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of your determination letters 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.[13]

How to submit. The complaint may be submitted online here, faxed to (503) 378-4351, or mailed to the following address:

Department of Consumer & Business Services
Insurance Division
P.O. Box 14480
Salem, OR 97309-0405[14]

Once you have filed your complaint, you will be notified that your complaint has been received and assigned to an advocate.[15] The advocate will send a copy of your complaint to your health insurer for a response. Your health insurer has three weeks to respond.16] The advocate will analyze the response and any supporting documents.[17] Following an investigation, the advocate will notify you of his or her findings. The Division can force the insurance company to comply with the policy, fine the company, or revoke the company’s license.[18] A full investigation may take up to 60 days to complete.[19]

You can contact the Oregon Division of Financial Regulation at (888) 877-4894. The Division is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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. 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 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.

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]

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]

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]

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]

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]

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]

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]

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.

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 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 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.

The internal appeals process should take a maximum of 30 days unless you and your insurance company agree to a longer time period.[2]

During 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. You are entitled to an external review if your insurer denies your coverage after an internal appeal. You are entitled to expedited external review if your medical situation is urgent and waiting 30 days for the requested treatment would jeopardize your life or ability to function.

You should send your request for an external review to the Governor’s Office for Consumer Health Assistance (“Governor’s Office”) within four months from when your insurer sent you the final decision.[4] The Governor’s Office will then assign an external review organization to review your claim.[5]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • Name of applicant;
  • Name, address, and telephone number of the insured person;
  • Name of the patient (if different from the applicant);
  • Name, address, and telephone number of the health insurer;
  • Insurance identification number, claim or reference number;
  • Employer name and telephone number;
  • Name and address of your treating physician or health care provider;
  • The name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • The reason for denial;
  • Brief description of the claim;
  • Description of the health care service or treatment in dispute; and
  • The health care provider certification form on page 6 of the external review packet (this form only needs to be completed if you are requesting an expedited review).[6]

Supporting documents. You should include the following documents with your request:

  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the determination letter from your health insurer;
  • A copy of your insurance policy; and
  • Any new information or documentation not included with your request for an internal appeal.[7]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas, NV 89101[8]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Office for Consumer Health Assistance at (702) 486-3587 or (888) 333-1597 for instructions on the fastest way to submit your request and supporting documentation.[9]

The external review process should take no longer than 15 days.[10] If you request an expedited external review, the Office for Consumer Health Assistance will let you know within 72 hours whether your claim is eligible for an expedited review.[11] If your claim is eligible, you should receive a decision within four days.[12]

If you are a Nevada resident and you think your insurer has done something illegal or unethical, you can file a complaint with the Nevada Division of Insurance (“Division”).

Complaint information. You can find a copy of the complaint form here. 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;
  • Policy number, claim number, date of loss/incident, if applicable;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[13]

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.[14]

How to submit. The complaint may be submitted online here or mailed to one of the following addresses, whichever is closest to you:

Nevada Division of Insurance
1818 E. College Pkwy. #103
Carson City, NV 89706

— or —

Nevada Division of Insurance
2501 E. Sahara Ave. #302
Las Vegas, NV 89104 [15]

Your health insurer should respond to your complaint within 28 calendar days. If you have not heard from the Division within 30 days, you should contact the Division to follow up.[16] The Department will investigate your claim and can require the health insurer to comply with the policy or issue a citation or fine for any violations.

You can contact the Nevada Division of Insurance at (775) 687-0700 (Carson City office), (702) 486-4009 (Las Vegas office) or toll-free at (888) 872-3234. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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.

Ask for an expedited urgent care request, if applicable. If your situation is urgent, you should ask your insurer for an expedited urgent care request. Your situation is urgent if waiting for 35 days for your requested treatment:

  • Could seriously jeopardize your life, health, or ability to regain function;
  • Could result in you experiencing severe and unmanageable pain; or
  • The requested treatment would be significantly less effective if it were delayed.

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.

The internal appeals process should take a maximum of 35 days for a standard internal appeal and three business days for an expedited urgent care request.[2]

During 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 Idaho law, you are entitled to request an external review in the following circumstances:

  • Your situation is urgent;
  • If you have not received a decision within 35 days if you requested standard internal appeal or within three business days if you requested an urgent care request;[4]
  • Your insurer denies your internal appeal.

Please note that if your situation is urgent, you do not need to wait for a decision from your insurer. You can request an expedited external review at the same time that you request an expedited urgent care request from your insurer.[5]

You should submit your request for external review to the Idaho Department of Insurance (“Department”) within four months of the date on the final determination letter from your insurer.[6] You can find a copy of the external review request form here.

 Information. You should include the following information with your request:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The name, address, and telephone number of the insurance company;
  • Policy identification number and claim number;
  • The insured individual’s employer name and telephone number;
  • The name, address, and telephone number of the patient’s health care provider;
  • The name of the contact person at the health care provider’s office; and
  • The reason for and details of the denial of coverage.

Supporting documents. You should include the following documents with your request:

  • A signed medical release form (available here);
  • A photocopy of your insurance ID card or other evidence showing you are insured with the health carrier named in your request;
  • A copy of the final determination letter from your health carrier;
  • A copy of your certificate of coverage or policy benefit booklet, which lists the benefits under your health plan;
  • A signed “Certification by Treating Health Care Provider” form available in this packet (this form is for expedited external reviews only.[7]

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request to the following address:

Idaho Department of Insurance
Attn: External Review
700 W. State Street, 3rd Floor
P.O. Box 83720
Boise, ID 83720-0043[8]

How to submit an expedited external review request. If you are requesting an expedited external review, you should contact the Department for instructions on how to submit required forms.[9] You can reach the Department at (208) 334-4250 or (800) 721-3272.

The external review process should take no more than 42 days from the date the independent review organization receives your request. If you requested an expedited external review, the process should take no more than 72 hours after the independent review organization receives your request.[10]

If you are an Idaho resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.[11]

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;
  • Policy number, claim number, and date of loss;
  • 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.[12]

How to submit. You can submit the complaint and supporting documents online here, fax them to (208) 334-4319, or mail them to:

Idaho Department of Insurance
Consumer Affairs Section
700 W. State Street, 3rd Floor
Boise, ID 83720-0043[13]

The Consumer Services Division of the Department will research, investigate, and resolve your complaint.

You can contact the Idaho Department of Insurance at (208) 334-4319 or (800) 721-3272. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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.

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.[2]

During 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 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.[4]

You can request an expedited external review if you need urgent medical care, as determined by your health care provider.[5] 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.[6]

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.[7] 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.[8]

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.[9]

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.[10]

If you are a Montana resident and you still lack 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 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.[11]

Supporting documents. You should also submit the following supporting documents with your complaint:[12]

  • 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 (406) 444-1980, or mailed to the following address:[13]

Commissioner of Securities and Insurance
Montana Department of Insurance
840 Helena Avenue
Helena, MT 59601

Once your complaint is filed, you will receive confirmation and an assigned file number.[14] 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.[15] 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.[16] The complaint process may take up to 90 days.

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.

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 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.

The internal appeals process should take a maximum of 45 days of receiving your request.[2] If you requested an expedited internal review, your insurer should provide you with a decision within 72 hours for your request.[3]

During an external review, an independent third party reviews your insurer’s decision.[4] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Wyoming law, you are entitled to request an external review if your insurer denied your coverage after an internal appeal and the denial was based on lack of medical necessity.[5]

You are also entitled to an expedited external review in circumstances where a delay of 45 days would jeopardize your life, health, or ability to regain function or if your claim concerns a request for an admission, availability of care, or continued stay or services for which you received emergency services but have not been discharged from a health care facility.[6] You can request an expedited external review at the same time that you file for an expedited internal review.[7]

You should submit your request for an external review to your health insurer within 120 days from when your insurer sent you the final decision.[8] Your health insurer must provide you with information regarding how to request an external review with your denial letter. You can use the insurance company form or the Wyoming Insurance Department form, which can be found here.[9]

Upon receipt of your request, your health insurer will forward your request to an independent review organization for review and notify the Insurance Department.[10]

Information. You should include the following information in your request:

  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • Subscriber or member number and insurance claim or reference number;
  • The name and address of your treating health care provider and the name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • Brief description of decision in dispute; and
  • The health care provider certification in the external review packet (This form is only required for expedited external reviews).[11]

Filing fee. You must submit a $15 filing fee by check or money order made payable to the Wyoming State Treasurer with your request. The fee may be waived for financial hardship.[12] If you believe you have a financial hardship, complete the “Certification of Qualification for Fee Waiver” in the external review request form.[13] If you complete that section, do not submit the filing fee.[14]

Supporting documents. You should include the following documents with your request:

  • A copy of the denial letter from your health insurer;
  • A copy of your insurance card or other evidence showing coverage; and
  • Any new information and documentation that you had not included with your prior request for an internal appeal.

The external review process should take no more than 45 days after the external review organization receives your request.[14] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[15]

If you are a Wyoming resident and have completed the internal appeal and external review processes, you can file a complaint with the Wyoming Department of Insurance (“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, if different than the Complainant;
  • The name, address, and telephone number of insurance company;
  • The name and title of any person you’ve spoken with about your claim at the insurance company as well as the date and place;
  • Policy number, group name or number, claim number, date of coverage, and date of loss;
  • 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.[17]

How to submit. The complaint may be submitted online here or mailed to the following address:

Wyoming Insurance Department
106 E. 6th Avenue
Cheyenne, WY 82001[18]

The Department will investigate your complaint and attempt to reach a resolution with your health insurer.

You can contact the Wyoming Insurance Department at (307) 777-7401. The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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 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.

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.[2]

During 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 Utah law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal.

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function.[4] If you are requesting an expedited external review, you should ask your insurer if you can also skip the internal appeal process altogether.

You should submit your request for an external review to either your health insurer or the Utah Department of Insurance (“Department”) within 180 days of your insurer’s last denial letter.[5] You can find a copy of the Health Benefit Plan Independent Review Process request form here.

Information. You should include the following information with your request:

  • The name of the person requesting the review;
  • The name, address, telephone number, and email address of the insured;
  • The name of the insurance company;
  • Insurance identification number and type of coverage;
  • The name and telephone number of your employer;
  • Reason for denial; and
  • A description of the service or treatment in dispute; and
  • “Certification of Treating Health Care Provider for Expedited Consideration of a Patient’s Independent Review” form on page 5 of the request packet (this form is for expedited external review requests only).[6]

Supporting documents. You should include the following documents with your request:

  • A signed medical records release form (included with external review request packet);
  • A copy of your insurance card or other evidence of coverage;
  • A copy of the final decision letter from your health insurer; and
  • Any additional or new information or documentation not included with your request for an internal appeal.

Submitting a standard external review. If you are requesting a standard external review, you should submit your request by fax to (801) 538-3829, by email to [email protected], or by mail to the following address:

Health Benefit Plan Independent Review Process
Utah Insurance Department
Suite 3110, State Office Building
Salt Lake City, UT 84114[7]

The external review process should take no more than 45 days after the independent review organization is assigned to your case.[9] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the independent review organization.[10]

If you are a Utah resident and your claim is denied after the external review process, you can file a complaint with the Utah Attorney General’s 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, and telephone number of insurance company;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents. You should submit the following documents as supporting information:

  • 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[11]

How to submit. The complaint may be submitted online here or mailed to the following address:

Utah Attorney General’s Office
Criminal Investigations Unit
5272 S. College Dr., Suite 200
Murray, UT 84123[12]

The Attorney General’s Office will forward a copy of your complaint to the insurance company and request a response. The insurer has ten days to respond to the complaint. The complaint process typically takes between three and six weeks to complete. The Attorney General’s Office can require the insurer to reverse its decision and provide coverage.

If you have questions regarding insurance appeals, you can contact the Utah Department of Insurance at (801) 538-3890 or (800) 439-3805 (in-state). The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

If you have questions regarding filing a complaint, you can reach the Attorney General’s Office at (800) 244-4636. The Attorney General’s Office is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

If your situation is not urgent and insurer denies your claim, the first step may be to request an informal reconsideration.[1] The informal reconsideration process provides an opportunity for your health care provider and the insurer to discuss your medical condition in detail and, if possible, resolve the matter without a formal appeal.

Not all insurers require an informal reconsideration. Check your policy or call your insurer to determine whether your insurer mandates this step. If your insurer does require it, call or write to your insurer and ask it to reconsider its decision not to cover your treatment.[2] This process should take no more than 30 days. If your insurer denies your claim again, request a formal appeal.[3]

If your insurer does not require an informal reconsideration or if your insurer denied your claim after the information reconsideration process, you should request a formal appeal (also referred to as an internal appeal). This means you can ask your insurer to conduct a full and fair review of its decision.

To request a formal appeal, you should complete the following steps:

  • 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. You can use Arizona’s “Health Care Appeal Request Form” located here.
  • 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.

You must request a formal appeal within 60 days of receiving your last denial letter.

The formal 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.[4]

During an external independent review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

If your insurer denies your claim after conducting a formal appeal, you can request an external independent review of the insurer’s decision.[6] You must file your written request for an external independent review within four months from the date that your insurer sent you the last decision.[7]

Expedited medical review. If your situation is urgent, you can skip the informal reconsideration process and request an expedited medical review.[8] Your situation is urgent if a delay in treatment could cause a significant negative impact on your medical condition. To request an expedited medical review, ask your health care provider to send the “https://insurance.az.gov/sites/default/files/documents/files/APPEALS_PROVIDER_CERTIF.pdf” to your health insurer along with supporting documentation.[9] Your health insurer should make a decision within one business day after receiving the form.[10]

Expedited appeal. If your insurer denies your claim again, ask your health care provider to submit a written expedited appeal to your insurer. Your health care provider should include any additional reasons and supporting documentation for the requested services. Your health insurer should make a decision within three business days of receiving the written expedited appeal.[11]

Expedited external independent review. If treatment is denied again, you have five business days to request an expedited external independent review.[12]

You should submit your request for a standard or an expedited external independent review to your health insurer, which will then forward the request and all documentation related to your appeal to the Arizona Department of Insurance (“Department”).[13]

The Department will then select an independent third party to review your insurer’s decision. The reviewer’s decision is binding on both you and your health insurer.[14] You should include any new information in your request for an external appeal.

The external independent review process should take no more than 45 days. If you request an expedited external independent review, the process should take no longer than four business days after your request is received.[15]

If you are an Arizona resident and your insurer denies your coverage after the external independent 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 from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The state where the insurance plan was purchased;
  • Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.[16]

Supporting documents

You should submit any letters, emails, forms, insurance policies, proof of payment, or other documents that will help the Department assist you with your complaint.[17]

How to submit

The complaint may be submitted online here, emailed to [email protected], faxed to (602) 364-2505, or mailed to the following address:

Arizona Department of Insurance
Consumer Affairs Division
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269[18]

What happens after the Department receives my complaint?

The Department will typically research, investigate, and resolve individual consumer insurance complaints. The Director of the Department may examine your account, records, documents, and transactions. He or she may also question witnesses, request additional documents from other parties, and hold a hearing.[19] The Department will then provide you with a decision.

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

You can contact the Department at (602) 364-2499 or (800) 325-2548 if you live in Arizona but are outside the Phoenix area. The Department telephone line is open from 8:00 a.m. to 4:00 p.m. Monday through Friday.

If your health insurer denies your claim, you have the right to a first level review (also known as 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 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.[2]
  • 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.

If you have a group plan and your insurer denies you coverage after you requested a first level voluntary review, you must then request a second level voluntary review.[3] During the second level voluntary review, you will have the opportunity to present your case and your health care provider may speak on your behalf directly with the review panel or expert reviewing the case. These rights are available to you in the first level of review if you have an individual health plan.[4] You may obtain a second level review by contacting your insurer. Your insurer will provide you with information on how to request a second level review and what documents, if any, are required in order to request a second level review.

The first and second level review processes should each take a maximum of 30 days.[5] You can skip the first and second level review processes and request an expedited external review in urgent situations.[6] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

If your insurer still denies you coverage after you requested a first and, if applicable, second level review, you can request an external review of the insurer’s decision.[7] If your situation is urgent, you can request an expedited external review. Your insurance company must provide you with information about requesting an expedited external review.[8] During an external review, an independent third party reviews your insurer’s decision.[9]

To request an external review, you should take the following steps:

  • Request documents from your insurer. Contact your insurer and request an external review form and a consent form that authorizes your insurer to release your records to an external review entity.[10]
  • Complete and submit forms. Complete and submit to your insurer the external review form, the consent form, and new information and documentation within four months of receiving the first level review decision or, if applicable, within 60 days of receiving the second level review decision.[11]

Once you submit your request for an external review to your insurer, the insurer will then forward the request to the Division of Insurance, which will assign the review to an external review entity.[12] The external review entity will review your medical records, your health care provider’s recommendation, consulting reports, any medical necessity criteria, and any medical or scientific evidence that is relevant to your case.[13]

The external review process should take no more than 45 days.[14] If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[15]

If you are a Colorado resident and your insurer denies your coverage after the external review process, you can file a complaint with the Colorado Division of Insurance (“Division”).

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 from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The state where the insurance plan was purchased;
  • Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.

You should also submit the following documents as supporting information:

  • 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.[16]

You can locate and submit the complaint online here.

The Division will assign an analyst to review your complaint and conduct an investigation.[17] The analyst will provide a copy of your complaint to your insurer, and your insurer will have approximately 20 days to respond.[18] The analyst will then conduct an investigation or examination to determine if the insurer has violated a law or regulation, and if so, will order the insurer to pay for treatments or services that were wrongfully denied or withheld.[19]

You can contact the Colorado Division of Insurance at (303) 894-7490 if you are inside the Denver metro area or (800) 930-3745 if you are outside the Denver metro area to speak with a consumer affairs representative.

If you have a group health plan and your insurer denies your claim, you have the right to two levels of internal review (sometimes referred to as an internal appeal).[1] This means you can ask your insurer to conduct a full and fair review of its decision.

First level internal review. To request the first level review, 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 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 review if one of the following applies:

  • Waiting 30 to 60 days for your requested treatment would jeopardize your life, health, or ability to regain function;
  • Your health care provider requests an expedited decision from your health insurer;[2]
  • Your medical condition would result in severe pain that cannot be adequately managed without the requested treatment or service; or
  • You are experiencing a medical emergency.[3]

If you believe you qualify for an expedited internal review, contact your insurer immediately and ask for instructions on how to request one.[4]

  • 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.

Second level internal review. Your health plan should also offer a second level internal review.[5] This process is optional. Your insurer will contact you after denying your claim in the first level internal review to provide you instructions on the second level internal review.[6]

If you choose to request a second level internal review, the health insurer will select an internal review panel to review the insurer’s decision.[7] You have the right to attend the panel review hearing, present your case to the panel, submit any additional supporting information or documentation, ask questions of health care professionals on the panel, and be assisted or represented by a person of your choosing.[8] If your case is under expedited internal review and your health insurer is unable to contact you to ask if you want a second level internal review, the insurer will automatically convene a second level review panel.[9]

Both the first and second level internal review combined 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.[10] If you requested an expedited internal review, you should receive a decision within 72 hours of your request.[11] If the insurer fails to meet these time frames, it must approve your claim request.[12]

During an external review, an independent third party reviews your insurer’s decision.[13] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New Mexico law, you are entitled to request an external review if your insurer denies your coverage after the internal review process.[14]

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your health, life, or ability to function. You can also request an expedited external review at the same time that you request an expedited internal review.[15]

You should submit your request for an external review to the New Mexico Office of Superintendent of Insurance (“Office”) within 120 days from when your insurer sent you the most recent decision.[16]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • The name, address, and telephone number of the patient;
  • The type of complaint;
  • Identification number, group number, and name of employer;
  • The type of health care plan;
  • The name of the insurance company; and
  • Summary of your complaint.[17]

Supporting documents. You should also include the following supporting documents with your request:

  • A signed medical records release form (included in the external review form packet);
  • Any new information or documentation not included with your request for an internal review.

Submitting the external review. You can submit your request for an external review in the following ways:

  • By fax to (505) 827-6341l
  • By email to [email protected] (use the subject line “external review request”); or
  • By mail to the following address:

Superintendent of Insurance
Attn: Managed Health Care Bureau –
External Review Request
P.O. Box 1689
1120 Paseo de Peralta
Santa Fe, NM 87504-1689[18]

The external review process should take no more than 45 days.[19] If you request an expedited external review, the process should take no longer than 72 hours.[20]

If you are a New Mexico resident, you have coverage through a managed health care insurer, and you believe your insurer did something illegal or unethical, you can file a complaint with the Office.

Complaint information. Your complaint should include the following information:

  • The name, address, telephone number, and email address of the insured;
  • The type of complaint;
  • The name of your employer and type of plan;
  • The name of the insurance company;
  • The reason for the complaint;
  • The level your claim has reached in the internal and external review processes;
  • The details of your complaint; and
  • What you think would be a fair resolution.[21]

Supporting documents. You should submit the following documents as supporting information with your complaint:

  • A copy of your benefits booklet;
  • A copy of your insurance policy;
  • A copy of all correspondence related to your claim;
  • A copy of your adverse benefit determination letter; and
  • Copies of any supporting documents from your healthcare provider.[22]

How to submit. You can submit your complaint and supporting documents in the following ways:

  • Online here;
  • By email to [email protected]
  • By fax to (505) 827-4734; or
  • By mailing a copy to the following address:

Office of Superintendent of Insurance
1120 Paseo de Peralta
Santa Fe, NM 87501[23]

The Office will contact your health insurer by mail or phone depending on the complexity of your claim. If it contacts your insurer by mail, the insurer must respond within 10 business days. Once the Office receives the insurer’s response, it will attempt to resolve the issue with your health insurer and will provide you with the results of its investigation.[24]

If you are a New Mexico resident and your insurer denies your claim after the external review process, you can file a complaint with the New Mexico Attorney General’s Office. A copy of the complaint form can be found here.

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, and telephone number of the of insurance company;
  • What actions you have taken to resolve the issue;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents. You should submit the following documents as 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[25]

How to submit. You can mail the complaint and supporting documents to the following address:

New Mexico Attorney General’s Office
Consumer and Family Advocacy Services Division
P.O. Drawer 1508
Santa Fe, NM 87504-1508[26]

The Attorney General’s Office will investigate and may refer your complaint to the Office of Superintendent of Insurance for resolution if it determines that the Office of Superintendent of Insurance is better able to assist you with your complaint.

You can contact the New Mexico Attorney General’s Office at (866) 627-3249 or (505) 827-6000 or (505) 222-9100. The Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

You can contact the Office of Superintendent of Insurance at (505) 827-3928. The Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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 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.

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.[2]

During 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 North Dakota law, you are entitled to request an external review if you are not satisfied with the outcome of your internal appeal, or if your insurer waives the internal appeal, you may request an external appeal.[4]

For most plans, you can also request an expedited external review in urgent situations. If your situation is urgent, you should contact your insurer and find out if you can skip the internal appeals process altogether and request an expedited external review immediately.[5]

You should submit your request for an external review to either your health insurer or the North Dakota Department of Insurance (“Department”) by mail to the following address:[6]

North Dakota Department of Insurance
600 E. Boulevard Ave., #401
Bismarck, ND 58505.

You must file your written request for an external review within four months from the date that your insurer sent you the final decision.[7] If you submit your request to your health insurer, your insurer will forward your request to the Department.[8] You should include any new information and documentation that you did not include with your previous request for an internal appeal with your request.

The external review process should take no more than 45 days from the date your request is accepted by the external review organization for review.[9] If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[10]

If you are a North Dakota resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department. You can find a copy of the complaint form here.

Complaint information. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • The name and address of the agent involved, if applicable;
  • Policy number and date of loss;
  • The name and address of the adjusting company, if applicable;
  • The name and telephone number of adjuster, if applicable;
  • Assistance requested from Department; and
  • The details of the complaint.

Supporting documents. You should submit the following supporting documents with y 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.[11]

You should not send copies of any doctor or hospital bills unless there is a problem with the bill itself.[12]

How to submit. The completed form and supporting documents should be mailed to the following address:

North Dakota Insurance Department
600 East Boulevard Avenue
Bismarck, ND 58505-0320[13]

The Department will review your complaint and attempt to resolve the issue with your health insurer. Within a week of receiving your complaint, you will receive a written acknowledgment. In most cases, an investigator will send a copy of your complaint to the insurance company and request an explanation of its position. The Department will determine within three weeks after receiving a response from the insurer whether further action is needed. A complaint can take up to 45 days to resolve, but may take longer for complex issues. The Department may require the insurer to pay your claim, refund your premium, or issue a citation or fine the company for violations of the contract or state law.

You can contact the North Dakota Department of Insurance at (800) 247-0560. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

If your insurer denies your claim, you have the right to file a grievance.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 file a grievance.

Collect information. In addition to the determination letter, collect 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 a 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 of urgent care requests. You can request an expedited review if you require urgent care. Your request is urgent if:

  • Waiting 30 to 60 days to receive the requested service or treatment could seriously jeopardize your life, health, or ability to regain function;
  • You would be subjected to severe pain that cannot be adequately managed without the requested treatment or service, or
  • Your case involves an urgent care request involving an admission, availability of care, continued stay, or health care service and you have received emergency services but have not been discharged from the facility.[2]

Contact your insurer to ask for instruction 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 grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The grievance 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.[3] If you have requested an expedited grievance, the process should take no more than 72 hours.[4]

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under South Dakota law, you are entitled to request an external review if your insurer denies your coverage after a grievance.

You can also request an expedited external appeal if:

  • Your medical situation is urgent and waiting would jeopardize your life or ability to function;
  • The initial denial of coverage is based on the health insurer’s determination that the treatment is experimental or investigational; or
  • Your physician certifies in writing that the requested service or treatment would be significantly less effective if not promptly initiated.[6]

 You can request an expedited external review while you request an expedited grievance review.[7]

You should submit your request for an external review to the South Dakota Division of Insurance within four months from when your insurer sent you the final decision.[8]

Information. You can find a copy of the external review request form here. Your request should include the following information:

  • The name of the applicant;
  • The name, address, email address, and telephone number of the insured/patient;
  • The name and address of the insurance company;
  • The name, email address, and telephone number of the insurance company contact person;
  • Insurance identification number and claim/reference number;
  • The name and telephone number of your employer;
  • The name and address of your health care provider;
  • The name and telephone number of the contact person at your health care provider’s office;
  • Your medical record number;
  • Reason for health care denial; and
  • Summary of external review request.[9]

Supporting documents. You should include the following documents with your request:

  • A filing fee of $25 (check or money order) made payable to the South Dakota Division of Insurance;
  • A copy of your insurance card or other evidence of coverage;
  • Final determination letter from your health insurer;
  • Copy of certificate of coverage or insurance policy benefit booklet;
  • Any relevant medical records;
  • Information from your health insurer related to the denial;
  • Any relevant peer literature or clinical studies;
  • Any additional information from your health care provider; and
  • Any new documentation or information not previously submitted during the grievance process.[10]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

South Dakota Division of Insurance
124 S. Euclid Avenue, 2nd Floor
Pierre, SD 57501-3185[11]

Submitting an expedited review. If you are requesting an expedited external review, call the Division of Insurance at (605) 773-3563 for instructions on submitting your request.[12]

The external review process should take no more than 60 days.[13] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[14]

Both the South Dakota Division of Insurance (“Division”) and Office of Attorney General (“Office”) handle complaints involving health insurance companies. If your case involves a claim dispute (denial of service or treatment, payment for already received services), you should file your complaint with the Division. If your case involves possible fraud or misleading or deceptive practices, you should file your complaint with the Office. If you are unsure where to file your complaint, you should contact the Division of Insurance or Office of Attorney General prior to completing the complaint form and they can assist you.

If you are a South Dakota resident and your claim is denied after the external review process, you can file a complaint with the Division.

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;
  • The name of the insurance company;
  • The type of insurance, policy number, and claim number; and
  • A description of the complaint.

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of determination letters 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.[15]

How to submit. The complaint may be submitted online here, faxed to (605) 773-5369, or mailed to the following address:

South Dakota Division of Insurance
124 S. Euclid Avenue, 2nd Floor
Pierre, SD 57501[16]

The Division of Insurance will investigate your complaint and notify you of its findings.

If you are a South Dakota resident, you can file a complaint with the South Dakota Office of Attorney General, Division of Consumer Protection (“Division of Consumer Protection”).

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, and telephone number of insurance company;
  • Actions you have taken to resolve the issue; and
  • The details of the complaint.

Supporting documents. You should submit the following supporting documents with your complaint:

  • A signed medical records release form, available here;
  • A copy of your insurance card;
  • Copies of determination letters 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.[17]

How to submit. The complaint may be submitted online here, faxed to (605) 773-7163, or mailed to the following address:

Office of Attorney General
Division of Consumer Protection
1302 E. Hwy. 14, Suite 3
Pierre, SD 57501-8053[18]

Once the Office of Attorney General receives your complaint, an investigator will review it and forward a copy to your health insurer. Your health insurer will have 20 days to respond to your complaint. The Division of Consumer Protection may begin an investigation or mediate the claim between you and your health insurer.[19]

You can contact the South Dakota Office of Attorney General at (800) 300-1986 (in-state) or (605) 773-4400. The Attorney General’s Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

You can contact the Division of Insurance at (605) 773-3563. The Division is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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 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.

The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment. The internal appeal must be completed within a maximum of 60 days if you already received services or treatment.[2]

During 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. You are entitled to an external review if your insurer denies your coverage after an internal appeal. Additionally, if your medical situation is urgent and waiting will jeopardize your life or ability to function, you are entitled to an expedited external review.[4]

You must submit your request for external review to the Nebraska Department of Insurance (“Department”) within four months from when your insurer sent you the final decision.[5] Your health insurer should have provided you with a copy of the external review request form with your determination letter.[6] You can also find a copy of the external review request form here.

Information. You should include the following information with your request:

  • Name of applicant;
  • Name, address, and telephone number of the insured person;
  • Name of the patient;
  • Name, address, and telephone number of the health insurer;
  • Insurance identification number, claim or reference number;
  • Employer name and telephone number;
  • Name and address of your treating physician or health care provider;
  • The name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • The reason for denial;
  • Brief description of the claim; and
  • Description of the health care service or treatment in dispute.[7]

Supporting documents. You should also include the following supporting documents with your request:

  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of your insurance policy; and
  • Any additional information or documentation not included with your request for an internal appeal.[8]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

Nebraska Department of Insurance
P.O. Box 82089
Lincoln, NE 68501-2089[9]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Department at (877) 564-7323 for instructions on the fastest way to submit your request and supporting documentation.[10]

The external review process should take no longer than 45 days from when your request is received.[11] If you request an expedited external review, the process should take no longer than four business days after your request is received.[12]

If you are a Nebraska resident and you still lack 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, 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;
  • The name of the agent or adjuster;
  • Policy or claim number and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[13]

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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[14]

How to submit. The complaint may be submitted online here or mailed to the following address:

Nebraska Department of Insurance
941 O Street, Suite 400
P.O. Box 82089
Lincoln, NE 68501-2089 [15]

Once your complaint has been submitted, you will receive notification that the Department is investigating your claim.[16] A copy of your complaint will be sent to your health insurer, and the Department will request certain information from the insurer.[17] Your health insurer has 15 business days to respond to the Department’s request for information. An investigator will review information received from your insurer and provide you with notice of the outcome.[18] If the Department determines that your insurer has committed a violation, your complaint will be referred to the Legal Division for further review.[19] The Department can also force the insurer to comply with the policy.

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.

If your insurer denies your claim, you have the right to a first level 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 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 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.
  • Second level appeal. If your insurer denies your claim after the first level appeal, you may have to request a second level internal appeal. Your health insurer must notify you if it requires a second level appeal. It will provide you with instruction how to request the appeal and the deadline for filing the request.[2] During a second level internal appeal, you will have the right to appear in person before your health insurer’s representatives and the right to present your case directly to such representatives.[3]

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 have been denied for reimbursement.[4]

If you seek a second level of internal appeals, the process should take no more than 15 business days if you have not yet received the requested service or treatment and no more than 30 days if you have received the service or treatment but have been denied for reimbursement.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal but your insurer did not give you a decision within 60 days;[7] or
  • Your insurer denied you coverage after you requested an internal appeal.[8]

You can skip the internal appeals process and request an expedited external review if you have an emergency medical condition.[9] Your condition is considered an “emergency medical condition” if:

  • Your condition is sudden, unexpected, and requires immediate medical attention;
  • If waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your health insurer has determined that the requested treatment is experimental or investigational; or
  • Your health care provider certifies in writing that the requested treatment would be significantly less effective if not initiated promptly.[10]

If insurer has denied your health claim, you can submit a request for an independent medical review to the Department of Insurance within 120 days of receiving a final decision from your insurer.[11] You should contact the Kansas Department of Insurance (“Department”) at (800) 432-2484 to request a copy of the Independent Medical Review request form.[12] Note that the following plans are not eligible for independent medical review:

  • Medicare or Medicare supplement
  • Medicaid
  • Federal employee plans
  • Workers’ compensation
  • Self-insured employer plans

Supporting documents. You should include the following supporting documents with your request if your plan is eligible:

  • A letter summarizing your dispute,
  • Any new documentation that you had not included with your previous request for an internal appeal;
  • Copies of relevant medical records;
  • Your health care provider’s professional recommendation;
  • Consulting reports from other health care professionals and other documents submitted by your health insurer, you, or your health care provider;
  • Your insurance policy; and
  • All correspondence sent to you by your insurer[13]

How to submit a standard external review request. To request a standard external review, mail the form and supporting documentation to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612

How to submit an expedited external review request. To request an expedited external review, contact the Department at (800) 432-2484 and ask for an independent medical review coordinator to help you with the process.[14]

Within ten business days of receiving your request for external review, the Department will determine whether your situation qualifies for review by an independent review organization.[15] If your request is approved, the Department will forward your request to an independent review organization for further examination.[16]

The external review process should take no more than 30 business days after receiving your request for external review. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[17]

If you are a Kansas resident and your insurer denies your coverage after the external review process, you can file a complaint with the Kansas Department of Insurance (“Department”).

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of insurer;
  • Policy number, claim number, and date of loss; and
  • The reason for and details of the complaint.[18]

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 appeals and complaints;
  • Supporting documentation from your health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[19]

How to submit. The complaint and supporting documents can be submitted online here, faxed to (785) 296-5806, or mailed to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612-1678[20]

Once the Department receives your complaint, it will forward a copy to your insurance company for a response and send you a letter of acknowledgement.[21] If the health insurer has violated a law or regulation, the Department will request that the insurer take corrective action.[22]

You can contact the Kansas Department of Insurance at (785) 296-7829 or (800) 432-2484. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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 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.

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.[2]

During 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 Oklahoma law, you are entitled to an external review if your insurer denied your coverage after an internal appeal.

You can request an expedited external review if you need immediate medical care.[4] You should contact your insurer to determine whether you can also skip the internal appeal process altogether when requesting an expedited external review.

You are not eligible for external review if the requested treatment is not covered by your health plan or if your dispute involves a question of administration, such as whether you paid your premium on time.[5]

You should submit your request for external review to the Ohio Department of Insurance (“Department”) within four months from the date that your insurer sent you the final decision.[6]

Information. You can find a copy of the request form here. You should include the following information with your request:

  • The name of the applicant;
  • The name of the insured;
  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • Insurance identification number and insurance claim/reference number;
  • The name and telephone number of the employer;
  • The name and address of your treating healthcare provider;
  • The name and telephone number of the contact person with your healthcare provider;
  • Your medical record number;
  • The reason for the denial;
  • A description of the disputed decision; and
  • The health care provider certification form found on page 6 of the request packet (this step is only for expedited external review requests).[7]

Supporting documents. You should also include the following documentation:

  • A signed medical record release form (included in the external review form packet);
  • A copy of your insurance card;
  • A copy of the final determination letter from your health insurer;
  • A copy of your certificate of coverage or insurance policy benefit booklet; and
  • Any additional or new information and documentation not included with your request for an internal appeal.[8]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

Oklahoma Insurance Department
External Review
Five Corporate Plaza
3625 NW 56th Street, Suite 100
Oklahoma City, OK 73112-4511[9]

Submitting an expedited review. If you are requesting an expedited external review, you should call the Department at (800) 522-0071 or (405) 521-2828 to receive instructions on the fastest way to submit your request.[10]

The external review process should take no more than 45 days once the Department determines that your request is eligible for external review.[11] If you requested an expedited external review, the process should take no longer than four business days after your request is received.[12]

If you are an Oklahoma resident your claim is denied 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, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the insured individual, if different than the Complainant;
  • The name and address of insurance company;
  • The policy number and effective date of the policy;
  • The name, address, and telephone number of the agent;
  • The name, address, and telephone number of the adjuster; and
  • The details of the complaint.[13]

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.[14]

How to submit. The complaint may be submitted online here, faxed to (405) 521-6652, or mailed to the following address:

Oklahoma Insurance Department
Five Corporate Plaza
3625 NW 56th, Suite 100
Oklahoma City, OK 73112[15]

Once your complaint is received, the Department will assign it to a consumer assistance or claims analyst, and you will receive a letter of acknowledgement.[16] The analyst will contact your health insurer, which has 30 days to respond.[17] The analyst will contact you when he or she makes a decision.[18] The Department can force the health insurer to comply with the policy provisions, issue a citation or fine the company.

You can contact the Oklahoma Insurance Department at (800) 522-0071 (in-state only) or (405) 521-2991. The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter telling you that it would not cover your claim. Review this document so you can understand why your claim was denied 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. 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.

The internal appeals process should take a maximum of 30 days after your health insurer receives the appeal for services you have not yet received and a maximum of 45 days if you have received the service or treatment but are waiting for reimbursement.[2]

During 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 Texas law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal because it determines that the treatment is experimental, investigational, medically unnecessary, or inappropriate. You cannot ask for an external review if your policy does not cover the denied services.[4]

You can also request an expedited external review if you or your health care provider believes that your condition is life threatening or if your plan denies coverage for a prescription drug or intravenous infusion for which you are currently receiving benefits.[5] You should call your insurer and find out if you can skip the internal review process if you qualify for an expedited external review.

To request an external review, you should complete the following steps:

Complete request form. Your insurer should have provided you with the external review request form when it sent you the final adverse determination letter.[6] You should complete that form and submit it to your health insurer per the instructions included with the final adverse determination letter. You should also send any new information and documentation that you had not previously included with your request for an internal appeal.

Deadline. While there is no deadline to request an external review, you should file your request as soon as possible after you receive your determination letter.[7]

Next steps. Your health insurer will send the request to the Texas Department of Insurance (“Department”), which will assign your claim to an independent review organization.[8]

The external review process should take no more than 20 days from the date the external review organization receives your request.[9] If you requested an expedited external review, the process should take no longer than three business days after your request is received.[10]

If you are a Texas resident and you believe your insurer has done something illegal or unethical, you can file a complaint with the Department.

Complaint information. You should complete the complaint form located here. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name and address of the insured individual, if different than the Complainant;
  • The name of the provider;
  • The name of insurance company;
  • Policy number, claim number, and date of loss;
  • Type of insurance and reason for complaint;
  • 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 signed medical record release form (included with the complaint packet);
  • 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.[11]

How to submit. You can submit the complaint and supporting documents by using one of the following methods:

MC 111-1A
Consumer Protection
Texas Department of Insurance
P.O. Box 149091
Austin, TX 78714-9091

  • Deliver in person to the following address:

Texas Department of Insurance
Consumer Protection (111-1A)
333 Guadalupe Street
Austin, TX 78701[12]

Once the Department receives your complaint, it will contact your health insurer and attempt to resolve the dispute.[13] Your complaint will typically be resolved within 45 days from when the Department receives your complaint.[14] The Department can force your health insurer to comply with the policy and take enforcement action, including issuing a citation or fine, if the insurer violated a law or regulation.[15]

You can contact the Texas Department of Insurance at (800) 252-3439. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

Group plans. If you have a group health plan, you must first file a formal complaint with your health insurer before requesting an internal appeal.[1] Your complaint may be submitted orally (by phone) or in writing directly to your health insurer.[2] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint. You should follow those instructions.[3] The complaint process may take up to 44 days to complete.[4]

If your group health insurer denies your claim after submission of your complaint, you have the right to an internal appeal.[5] 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 appeal, if applicable. You can request an expedited appeal if your health care provider believes that your situation is urgent. In such case, ask your health care provider to call your insurer and ask for the expedited appeal.[6]
  • 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.

Individual plans. If you have an individual health plan, you must file a formal complaint with your health insurer either orally (by phone) or in writing.[7] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint, and you should follow those instructions for submitting your complaint.[8] The complaint process may take up to 44 days to complete.[9] If your complaint is denied, check to see if your insurer follows the internal appeals process.[10] If it does, follow the instructions above for submitting internal appeals. Otherwise, when you receive notice of the denial of your complaint, your health insurer will include instructions regarding how to submit your claim to external review.[11]

The internal appeals process should take a maximum of 45 days for both group and individual health plans.[12] The expedited appeals process should take no longer than 72 hours after your health insurer receives the expedited appeal request.[13]

During an external review, an independent third party reviews your insurer’s decision.[14] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

You can request an appeal in the following situations:

  • Your group health insurer denies your internal appeal;
  • Your individual health plan insurer follows the internal appeals process and your appeal is denied;[15] or
  • Your situation is urgent, in which case you would request an expedited external review.[16]

Your situation is considered urgent if one of the following applies:

  • Waiting up to 45 days to receive your requested treatment would seriously jeopardize your life, health, or ability to regain maximum function; or
  • You are currently receiving inpatient emergency services, have not been discharged from the facility yet, and your requested treatment relates to the emergency services.[17]

If you qualify for an expedited external review, you can request it at the same time that you request the expedited internal review.[18]

You should file your request for an external review within six months from your insurer’s most recent decision.[19] If your plan is a health maintenance organization (“HMO”), you should file your request with the Minnesota Department of Health. If your health insurer is an insurance company, you should file your request with the Minnesota Department of Commerce.[20] The respective Departments will assign your case to an external review agency who will then notify you and your health insurer of the assignment and their review of your case.[21]

Information. You can find the external review request form for HMO requests here and the request form for an insurance company here. You should include the following information in your request:

  • The name, address, and telephone number of the enrollee;
  • The name of the patient, if different than the enrollee;
  • The enrollee’s identification number;
  • If you are represented by another person, that person’s name, address, telephone number, and relationship to you; and
  • The name and address of your health plan.[22]

Supporting documents. You should also submit any new information or documentation that you did not previously include with your internal review request.[23] Your insurer will also submit documentation related to your appeal.

Filing fee. There is a $25 filing fee for submitting the request which will be refunded if you are successful.[24] If the filing fee would create a financial hardship, you can provide a written statement explaining why the fee would create such a hardship.

Submit for HMO. You can submit your HMO claim request by mail to:

Minnesota Department of Health
Attn: Managed Care Systems Section
P.O. Box 64882
St. Paul, MN 55164-0882[25]

If you are requesting an expedited review, you can make the request by phone to the Department of Health at (651) 201-5100 or (800) 657-3916. If mailing an application for an expedited review would unreasonably delay the review, you should fax the application to (651) 201-5186 or email it to [email protected].

Submit for Insurance Claim. You can submit your insurance company claim request by mail to:

External Review Process
Minnesota Department of Commerce
85 7th Place East
St. Paul, MN 55101[26]

If you are requesting an expedited review, you should fax the application to (651) 539-0105, email it to [email protected], or call the Department of Commerce at (651) 539-1600 or (800) 657-3602.

The external review process should take no more than 45 days after the case is received by the external review organization.[27] If you requested an expedited external review, the process should no longer than 72 hours after your request is received.[28]

If your health plan is an HMO and your coverage is still denied after the external review process, you can file a complaint with the Minnesota Department of Health. You can find a copy of the complaint form here. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The Complainant’s relationship to the insured individual;
  • The name of the insured individual, if different than the Complainant;
  • The date of birth of the insured individual;
  • The name of a family member you would like to be interviewed regarding the complaint (optional);
  • The name of health plan;
  • The type of coverage;
  • The enrollee/membership number and date of incident;
  • The name of the insured individual’s primary care physician; and
  • The details of the complaint; and
  • What you consider to be a fair resolution.[29]

You should also submit the following supporting documents:

  • A signed medical records release form (found in the complaint application);
  • A copy of your insurance card;
  • Any referrals, denials, or prior authorizations;
  • 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 doctor;
  • Copies of any bills and explanations of benefits;
  • A copy of your insurance policy; and
  • All responses from your insurer.[30]

The completed form and supporting documents can be faxed to (651) 201-5186, emailed to [email protected], or mailed to:[31]

Minnesota Department of Health
Managed Care Section
P.O. Box 64882
St. Paul, MN 55164-0882

Your complaint will be assigned to an investigator who will determine whether the HMO’s actions are in compliance with state law. If the Department suspects that the HMO has violated a law or regulation, the Department will refer your complaint for possible enforcement action, which may include a penalty or corrective action plan.[32] Most investigations are completed within 30 to 60 days.[33]

If your health plan is with an insurance company and your coverage is still denied after the external review process, you can file a complaint with the Minnesota Department of Commerce. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The Complainant’s relationship to the insured individual;
  • The name of the insured individual, if different than the Complainant;
  • The name and address of the insurance company;
  • The policy number, group number, certificate number, claim number, and date of loss/treatment;
  • The name of the employer, if a group plan;
  • The reason for the complaint; and
  • A description of the problem.[34]

You should submit the following documents as supporting information:

  • 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[35]

You can find a copy of the complaint form here. You can also submit your complaint and supporting documents online here or mail them to:[36]

Minnesota Department of Commerce
Attn: Consumer Protection & Education Division
85 7th Place East, Suite 500
St. Paul, MN 55101

The Department of Commerce will investigate your complaint and determine whether the insurance company is in compliance with state law. If the Department suspects that the insurer has violated a law or regulation, it can pursue enforcement action against the insurer.[37]

You can contact the Minnesota Department of Health at (651) 201-5100 or (800) 657-3916. The Department of Health is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

You can contact the Minnesota Department of Commerce at (651) 539-1600 or (800) 657-3602. The Department of Commerce is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

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 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.[2]
  • 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.

The internal appeals process should take a maximum of 30 days.[3] The initial denial letter from your health insurer will specify the amount of time they have to respond to your appeal.[4]

You can skip the internal appeals process and request an expedited external review in urgent situations.[5] Your situation is urgent if waiting 30 days would seriously jeopardize your life or your ability to regain function.

During an expedited external review, an independent third party reviews your insurer’s decision.[6] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal, but your insurer did not provide you with a decision within 30 days;[7]
  • Your insurer denied you coverage after you requested an internal appeal; or
  • You your situation is urgent situation (request an expedited external review).[8]

You can obtain the external review packet online here. This packet contains forms for both standard and expedited external reviews. Be sure to include the following information in your application:

  • The name, address, telephone number, and email address of the patient;
  • The name, address, telephone number, fax number, and email address of the insurance company;
  • The employer’s name;
  • The name and address of the treating health care provider, as well as the name, telephone number, and email address of the contact person; and
  • The reason for the health insurer’s denial.

You should submit the following supporting documents with your completed external review request:

Signed medical records release form (included in packet); AND

  • Any documentation not previously submitted during the internal appeal process; AND
  • Final determination letter from the health insurer; OR
  • Letter from health insurer stating it has waived the internal review process; OR
  • A copy of the request for internal appeal and a statement that no decision has been received for 30 days; OR
  • A completed request for expedited review (included in packet).[9]

If you are requesting a standard external review, you can submit the form and copies of all supporting documents by fax to (515) 281-3059, by email to [email protected], or by mail to:

Iowa Insurance Division
330 Maple
Des Moines, IA 50319[10]

If you are requesting an expedited external review, you must call the Iowa Insurance Division at (877) 955-1212 or (515) 281-6348 to receive instructions on the quickest way to submit the form and supporting documentation.[11]

The external review process will take no more than 60 days.[12] If you request an expedited external review, the process takes no longer than 72 hours after your request is received by the independent review organization.[13]

If you are an Iowa resident, you can file a complaint with the Iowa Division of Insurance (“Division”). You can obtain the complaint form here. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of the insured individual, if different than the applicant;
  • The name of insurance company;
  • Policy number, claim number, and date of loss or service;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

You should submit the following supporting documents along with the complaint form:

  • 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.[14]

The complaint may be submitted online here, faxed to (515) 281-3059, or mailed to the following address:

Iowa Insurance Division
Market Regulation Bureau
601 Locust Street, 4th Floor
Des Moines, IA 50309-3738[15]

Once you file your complaint, the Division will send you an acknowledgment letter. The Division will then request a response from your health insurer and begin reviewing the information. If the Division finds that the health insurer has violated a law, the Division will request that the insurer provide you with coverage or reimburse you. The Division may also order the insurer to pay a fine.[16] A final decision in your case may take up to six weeks.[17]

You can contact the Iowa Division of Insurance at (877) 955-1212 or (515) 281-5705. The Division is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

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]

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]

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]

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]

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]

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

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]

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.

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 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.[2]
  • 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

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.[3]

You can skip the internal appeals process and request an external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[5] You must request an external review within four months from the date that your insurer sent you the last decision.[6] During an external review, an independent third party reviews your insurer’s decision.[7]

You should request an external review from the Arkansas Insurance Department. You may call to request the form at (800) 852-5494 or print out a copy of the form here. The completed form should be mailed to:

Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, AR 72201-1904[8]

You should include any additional or new information and documentation not included with your request for an internal appeal with your request for an external review for consideration by the independent reviewer.

The external review process should take no more than 45 days. If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[9]

If you are an Arkansas resident and your insurer denies your coverage after the external review process, you can file a complaint with the Arkansas Insurance Department (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (i.e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The names of any other parties involved (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.[10]

You should also submit the following documents as supporting information:

  • 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.[11]

The complaint may be submitted online here, faxed to (501) 371-2749, or mailed to the following address:[12]

Arkansas Insurance Department
Consumer Services Division
1200 West Third Street

Little Rock, AR 72201-1904

The insurance commissioner or attorney general will assign someone to research, investigate, and resolve your complaint.[13] That person will examine your account, records, documents, and transactions.[14] He or she may question witnesses, request additional documents from other parties, and hold a hearing.[15]

You can contact the Arkansas Insurance Department at (501) 371-2640 or (800) 852-5494. The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.

After you file a complaint with the Insurance Department, you may then file a complaint with the Arkansas Attorney General’s Office.[16] To file a complaint with the Attorney General, complete this online form. A representative from the Attorney General’s Office may ask for copies of any supporting documents.[17]

Once the Attorney General receives your complaint, a representative will assign it to an investigator.[18] Within five business days, the investigator will send a copy of the complaint to your health insurer if mediation is appropriate or will provide you with information about other solutions.[19] Your health insurer has ten business days to respond to the complaint.[20]

You can contact the Attorney General’s Office at (501) 682-2007 or (800) 482-8982. The Attorney General’s Office is open from 7:30 a.m. to 6:00 p.m. Monday through Friday.

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 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 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. Your request must be submitted within 180 days of receiving notice that your claim for treatment or service has been denied.[2] 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.
  • Expedited internal appeal. You can file a request for an expedited internal appeal if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function or if your treating physician certifies that you may experience pain that cannot be adequately treated without the requested service or treatment.[3] You can submit your request in the same manner as a standard internal appeal request.

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.[4] An expedited internal appeal must be decided within 72 hours.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Louisiana law, you are entitled to request an external review if your insurer:

  • Has not sent you a decision on your internal appeal within 30 days;[7] or
  • Denies your internal appeal.[8]

You can also request an expedited external review if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function and you have also filed a request for an expedited internal appeal.[9]

You must submit a written request for a standard external review directly to your health insurer within four months of your insurer’s last decision.[10] However, if you are requesting an expedited external review, you should submit your request to your health insurer as soon as possible.[11] You should include any new documentation or information with your request for a standard or an expedited external review that you did not previously include with your request for an internal appeal.

Once your insurer receives your request, it will ask the Louisiana Department of Insurance (“Department”) to assign the request to an independent review organization.[12] You will then receive contact information for the review organization.[13]

Once an independent review organization receives notice that it will conduct your appeal, it will select one or more clinical peers to conduct the standard or expedited review.[14] A clinical peer is a licensed physician or other health care professional in the same or similar specialty that typically manages the medical condition or treatment under review.[15] The external review process should take no more than 45 days from the date the independent review organization receives your request.[16] If you request an expedited external review, the process should take no longer than 72 hours after your request is received by the health insurer.[17]

If your claim involves an experimental or investigational treatment, the external review organization must provide written notice of its decision within 20 days of receiving the clinical peer’s opinion in a standard external review and within 48 hours in an expedited external review.[18]

If you are a Louisiana resident and your insurer 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, 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 name of the employer, if it’s a group policy;
  • The policy number, group number, claim number, and date of loss or date of claim;
  • The reason for your complaint and a description of the problem; and
  • What you consider to be a fair resolution.

Supporting documents. You should also submit the following documents as supporting information:

  • A copy of your insurance card;
  • Copies of coverage denials or adverse benefit determinations from your insurer;
  • Copies of any correspondence between you and the insurance company;
  • 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.[19]

How to submit. The complaint may be submitted online here or mailed to the following address:

Louisiana Department of Insurance
P.O. Box 94214
Baton Rouge, LA 70804-9214[20]

After receiving your complaint, the Department will send you an acknowledgement letter, which will include your file number and the name of the compliance officer in charge of investigating your complaint.[21] The compliance officer will send a copy of the complaint to your health insurer and request a response. If the Department is unsatisfied with the insurer’s response, the Department will continue the investigation. If the health insurer violated a law or regulation, the Department will take administrative action against the insurance company.[22] The average complaint usually takes 45 days to resolve.[23] You will receive periodic updates about the status of your complaint, or you can check the status online here.[24]

You can contact the Louisiana Department of Insurance at (225) 342-5900 (local) or (800) 259-5300.  The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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.

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.[2]

If your insurer denies your coverage after an internal appeal, 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 can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function.[3]

You should file your request for an external review with the Mississippi Insurance Department (“Department”) within four months from when your insurer sent you the final decision.[4] You can find a copy of the form here.

Information. You should include the following information with your request:

  • The name of the person submitting the application;
  • The name, address, and telephone number of the insured;
  • The name of the patient (if different from the insured individual);
  • The name, address, and telephone number of the insurance company;
  • The insurance identification number and claim number;
  • The name and telephone number of the insured individual’s employer;
  • The name and address of the treating health care provider;
  • The name and telephone number of the contact person at the health care provider’s office;
  • The medical record number;
  • The reason for the denial;
  • A brief description of the claim; and
  • A description of the health care or treatment decision in dispute.[5]

Supporting documents. You should also submit the following supporting documents:

  • A signed medical records release form (included in the external review form packet);
  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of your insurance policy;
  • Any new information and documentation not included with your original request for an internal appeal; and
  • The health care provider certification form located in the external review packet (this form is for expedited external review requests only).[6]

Submitting a standard external review. If you are requesting a standard external review, you should mail the completed form and supporting documents to the following address:

Mississippi Insurance Department
Attn: Life and Health Actuarial Division
P.O. Box 79
Jackson, MS 39205 [7]

Submitting an expedited review. If you are requesting an expedited external review, you should call the Department at (601) 359-3569 and ask for instructions on the fastest way to submit your request.[8]

If the insurer determines that your requested treatment is “experimental,” the expedited external review process should take no more than five days and the standard external review process should take no more than 20 days.[9]

If the insurer denies your request for any reason other than the treatment being experimental, the expedited external review process should take no more than 72 hours and the standard external review process should take no more than 45 days.[10]

If you are a Mississippi resident and your claim was still denied 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, telephone number of the person filing the complaint (“Complainant”);
  • The Complainant’s relationship to the insured individual;
  • The name, address, email address, and telephone number of the insured individual, if different than the Complainant;
  • The name and address of the insurance company;
  • The policy number, claim number, and date of loss;
  • The reason for the complaint; and
  • The details of the complaint.[11]

Supporting documents. You should also submit the following supporting documents:

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Copies of explanations of benefits received;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[12]

How to submit. The complaint may be submitted online here, faxed to (601) 359-1077, or mailed to the following address:[13]

Mississippi Insurance Department
Attn: Consumer Services Division
P.O. Box 79
Jackson, MS 39205

Once the Department receives your complaint, you will receive an email acknowledgement and the complaint identification number.[14] The Department will provide a copy of your complaint to your health insurer. The complaint will then be reviewed by the Consumer Services Division, who will make a decision regarding your issue.[15] The process will take a minimum of 20 business days.[16] The Department can force your health insurer to comply with the policy, or issue a citation or fine if the insurer has violated a law or regulation.

You can contact the Mississippi Department of Insurance at (601) 359-2453 or (800) 562-2957. The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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.[2]
  • 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.

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.[3]

You can skip the internal appeals process and request an external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[5] During an external review, an independent third party reviews your insurer’s decision.[6]

Alabama participates in the external review process administered by the U.S. Department of Health and Human Services. You can obtain an external review request form by calling (800) 866-6205 and, once complete, you can fax it to (888) 866-6190 or mail the completed form to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.[7]

You must file your written request for an external review within 60 days from the date that your insurer sent you the final decision.

The external review process should take no more than 60 days. If you request an expedited external review, the process should take no longer than four business days after your request is received.[8]

If you are an Alabama resident and you have completed the external review processes but still lack access to a treatment, you can file a complaint with the Alabama Department of Insurance (“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 from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The state where the insurance plan was purchased;
  • Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.

You should also submit the following documents as supporting information:

  • 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.[9]

The complaint may be submitted online at: https://sbs-al.naic.org/Lion-Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanishVersion=N, faxed to (334) 956-7932, or mailed to the following address:

Alabama Department of Insurance
Consumer Services Division
P.O. Box 303351
Montgomery, AL 303351[10]

The Department will research, investigate, and resolve your complaint.[11] The Commissioner of Insurance will examine your account, records, documents, and transactions.[12] The Commissioner may question witnesses, request additional documents from other parties, and hold a hearing.[13] If the Commissioner determines that the insurer violated Alabama laws or regulations, it may order the insurer to give you the requested coverage or compensate you.[14]

You can contact the Alabama Department of Insurance at (334) 241-4141. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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.[2]
  • 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.

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.[3]

You can skip the internal appeals process and request an expedited external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] You can request an external appeal in the following circumstances:

  • You requested an internal appeal from your insurer, but your insurer did not provide you with a prompt hearing or a decision within 30 days (if you have not yet received the requested service or treatment) or 60 days (if you have received the service or treatment but are waiting for reimbursement);[7]
  • Your insurer denies your internal appeal;
  • Your situation is urgent (request an expedited external review);[8]
  • Your health insurer denied your claim because it deemed your requested treatment “experimental” and you meet all of the following criteria:
    1. You have a terminal condition with a substantial probability of death within two years or your ability to regain or maintain function would be impaired;
    2. You have already tried standard treatments, your health care provider certifies that the standard treatment is not medically indicated for your condition, or there is no standard treatment;
    3. Your health care provider recommends and certifies in writing that the proposed treatment is more beneficial to you than the standard treatment;
    4. Your health care provider has certified in writing that scientific studies, using accepted protocols and published in peer reviewed literature, demonstrate that the proposed treatment is likely to be beneficial to you than the standard treatment; and
    5. Your insurance policy says that the treatment should be covered, and the only reason it was not covered was because your insurer determined that it was experiment.[9]

You should submit a written request for a standard or an expedited external review to the Georgia Department of Insurance.[10] Your insurer should have provided you with instructions on how to submit the request and what information, documentation, and procedures are required for external review of your case.[11] If you cannot find the instructions, contact your insurer.

The external review process should take no more than 30 days.[12] If you request an expedited external review, the process should take no longer than 72 hours after your request is received by the independent reviewer.[13]

If you are a Georgia resident and your insurer denies your coverage after the external review process, you can file a complaint with the Georgia Department of Insurance (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint.

You should also submit the following documents as supporting information:

  • 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.[14]

The complaint and supporting documents may be submitted online here. Alternatively, the complaint and supporting documents can be faxed to (404) 657-8542 or mailed to:[15]

Georgia Department of Insurance
2 Martin Luther King Jr. Drive, Suite 716, West Tower
Atlanta, Georgia 30334

The Department will assign an investigator to your case. The investigator will then work with your health insurer and you to resolve the issue.[16] If the investigator determines that the insurer violated a law or policy, it will take corrective action.

You can contact the Georgia Department of Insurance at (404) 656-2070 (in the Atlanta metro area) or (800) 656-2298 (outside the Atlanta metro area). The Department phone lines are open from 8:00 a.m. to 7:00 p.m. Monday through Friday.

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 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 documents that your insurer sent 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.

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.[2]

During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say whether to approve a treatment or pay a claim.

In South Carolina, you can request a standard external review if you meet all of the following qualifications:

  • Your insurer denied, reduced, or terminated your requested service because it (1) did not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or (2) it was experiment or investigational and involves a life-threatening or seriously disabling condition; and
  • Your insurer is required to pay at least $500 for the requested treatment or service; and
  • You have completed the internal appeals process or meet an exception for this requirement.[4]

You can request an external review before completing the internal appeals process if you have not yet received your requested service and one of the following applies:

  • Your treating physician has certified in writing that you have a serious medical condition (if this is the case, you also qualify for an expedited external review);
  • Your requested service is experimental or investigational and your treating physician has provided you with required certifications;
  • Your insurer has not provided you with a written decision within the timeframe required for the internal appeals process even though you provided your insurer with all of the requested information; or
  • Your insurer waived the internal appeals process.[5]

In certain circumstances, you can request an expedited external review, which means you do not need to finish the internal appeals process and the independent review organization must provide you with a decision within three business days. You should consult with your insurer to determine whether you can skip the internal review process altogether. You can request an expedited external review in the following circumstances:

  • Your treating physician has certified in writing that you have a serious medical condition; or
  • You received emergency medical care, have not been discharged from a facility, and may be held financially responsible for the emergency medical care.[6]

Deadlines. You must submit a written request for a standard external review to your health insurer within 60 days from the date of the insurer’s final decision and within 15 days if you are requesting an expedited external review.[7] Your health insurer should have sent you information on how to submit the external review request when it denied your internal appeal.[8]

Supporting documents. You should include the following documents with your request:

  • A signed medical record release form (appendix B of the Patient’s Guide to External Review); and
  • Any new information and documentation that you did not include with your previous request for an internal appeal.[9]

If your insurer denied your claim because the requested treatment or service was considered experimental or investigational, you must include a letter or certificate from your physician.[10] The requirements for physician’s certification are included on page 7 of the Patient’s Guide to External Review.

Independent Review Organization’s Duties. Once your health insurer receives your external review request, it will assign your request to an independent review organization (“IRO”), send the IRO copies of all documents and information it relied upon in denying your request, and send you notice of these actions.[11] The IRO will contact you within five days of receipt of the external review request if it needs additional documents or information. You will have seven business days to provide them with the requested information.[12]

The external review process should take no more than 45 days once the IRO receives your request and documentation from your insurer.[13] If you requested an expedited external review, the process should take no longer than three business days after your request is received.[14]

If you are a South Carolina resident and your claim is denied after the external review process, you can file a complaint with the Consumer Services Division of the South Carolina Department of Insurance (“Division”).

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 and email address of the insured individual, if different than the Complainant;
  • The name and telephone number of insurance company;
  • The name and telephone number of the insurance adjuster or agent, if applicable;
  • The policy number, claim number, identification number, and date of loss;
  • The name of your employer, if applicable;
  • The type of insurance;
  • The reason for the complaint; and
  • The details of the complaint.[15]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of the determination letters 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[16]

The complaint may be submitted online here, faxed to (803) 737-6231, emailed to [email protected], or mailed to the following address:

Consumer Services Division
P.O. Box 100105
Columbia, SC 29202-3105[17]

Once the Division receives your complaint, it will forward a copy of your complaint to your health insurer for a response. Your insurer has ten days to respond. The Division will evaluate your case to determine whether your insurer violated any laws. If it did, the Division will refer the matter to the Investigative Division. The Division will notify you if it refers your case or if a decision is reached. The Division may require your health insurer to comply with your health policy and may also fine the insurer or issue it a citation.

You can contact the Department at (803) 737-6180 or (800) 768-3467. The Department is open from 8:00 a.m. to 6:00 p.m. Monday through Thursday and 8:00 a.m. to 5:00 p.m. on Friday.

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. Your insurer may offer two levels of internal appeals. The first level is required and the second level is optional.

To request a first level appeal, 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 appeal, if applicable. If you are requesting urgent care involving an admission, availability of care, continued stay, or health care service in which you have received emergency services but have not been discharged from the facility, you can request an expedited internal review.[2] Your insurer must provide you with information regarding how to submit the request and any required documentation you will need to submit with the request.[3] You can request an expedited appeal over the phone, in writing, or by email to your health insurer.[4]
  • 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.

If your insurer denies your claim after the first level internal appeal, you can request a second level of internal appeals.[5] This second level internal appeal is entirely optional.[6]

Your health insurer is required to provide you with notice and instruction on how to file a second level appeal with their denial letter following the first level internal appeal.[7] During a second level internal appeal, you have the right to:

  • Appear in person before a review panel convened by your health insurer;
  • Receive copies of all documents, records, and other information relevant to your request for services or treatment;
  • Present your case to the review panel;
  • Submit additional documentation and information to the review panel for their consideration; and
  • Ask questions of the review panel.[8]

The first level appeal 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.[9] The second level internal appeal should take a maximum of five business days following the review meeting.[10]

If you request an expedited internal appeal, your health insurer should send you a decision within 72 hours of receiving the request.[11]

During an external review, an independent third party reviews your insurer’s decision.[12] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Tennessee law, you are entitled to request an external review in the following circumstances:

  • Your insurer denies your internal appeal;[13]
  • Your insurer did not send you a decision on your internal appeal within the required deadlines.[14]

You can also request an expedited external review if your situation is urgent and waiting would jeopardize your life or ability to function.[15]  If your situation is urgent, you can request an expedited external review simultaneously with your request for a first level appeal.[16]

You should submit your request for an external review to your health insurer within six months from when your insurer sent you its final decision.[17] Your health insurer must provide you with instructions on how to submit your request.[18] You should submit any new information that you did not previously provide to your health insurer with your request.[19]

Once you submit your request for an external review, your health insurer will then send your request to an external review organization for review.[20] Your health insurer will also send you a notice that an external review organization has been assigned to your case and instructions on how and where to send additional information.[21]

The external review process should take no more than 40 days after the external review organization receives your request.[22] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[23]

If you are a Tennessee resident and your insurer still denies your claim after the external review process, you can file a complaint with the Tennessee Department of Commerce and Insurance, Division of Insurance (“Division”).

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 names of other parties involved;
  • The name of the insurance company, insurance agency, and agent/adjuster/appraiser;
  • The state in which you purchased the plan;
  • The policy number, certificate number, claim number, and date of loss;
  • The type of insurance and reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[25]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of determination letters 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.[26]

How to submit. The complaint may be submitted online here, faxed to (615) 532-7389, or mailed to the following address:

Consumer Insurance Services
500 James Robertson Parkway, 6th Floor
Nashville, TN 37243-0574[27]

The Division will forward a copy of your complaint to your health insurer, who has two weeks to respond. The Division will review the insurer’s response. If the Division determines that your insurer violated your insurance policy, the Division will require your insurer to comply. The complaint process time varies, but typically takes one month to complete.

You can contact the Tennessee Department of Commerce and Insurance at (615) 741-2241. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

If your insurer denies your claim because it determines that the services or treatment you requested were not medically necessary, you can request an informal reconsideration of the denial.[1] The informal reconsideration process provides an opportunity for your health care provider and the insurer to discuss your medical condition in detail and, if possible, resolve the matter without a formal appeal. You are not required to request an informal reconsideration; however, doing so may resolve your matter in less time and with less effort than is required for a formal first level appeal. You or your health care provider can call your insurer to determine if it offers this option.

If your insurer denies your claim because it determines that the service or treatment you requested was not medically necessary, you have the right to a formal first level appeal.[2] This means you can ask your insurer to conduct a full and fair review of its decision.

To request a formal first level appeal, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter telling 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 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, a clear statement from you explaining why you believe the insurer’s decision was wrong, 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.

You can file a first level grievance with your health insurer if your insurer denies your requested service or treatment for any reason other than medical necessity. Reasons may include availability, delivery, or quality of health care services; payment of claims; or any disputes arising from the contractual relationship between you and the health insurer.[3]

To file a first level grievance, you or your health care provider should submit a complaint in writing to your health insurer.[4] Be sure to follow your insurer’s instructions for filing the grievance closely.

If your insurer denies your claim after a first level appeal or first level grievance, you may (but are not required to) file a second level grievance with your insurer.[5] Your health care provider can submit the request for you.[6] Instructions for filing a second level grievance should have been included in the health insurer’s denial letter from the first level appeal or grievance.[7]

During a second level grievance, the health insurer is required to form a review panel and conduct a hearing, which you can attend either in-person or by phone.[8]The hearing must be held within 45 days from when your insurer receives your second level grievance request.[9]

If waiting 30 days for your requested treatment or service would seriously jeopardize your life or health, you or your health care provider can request an expedited first level appeal or grievance.[10] Instructions on how to request an expedited appeal or grievance should have been included in your health insurer’s denial of benefits letter.[11]

You can also request an expedited second level grievance if waiting an additional seven days for your requested treatment or services would seriously jeopardize your life or health. You can make this request even if you did not request an expedited first level appeal or grievance.[12]

The first level appeal or grievance should take a maximum of 30 days.[13] If you request a second level grievance, you should receive a decision within seven days following the hearing.[14] If you request an expedited appeal or grievance, you should receive a decision within four days of your insurer receiving your request.[15]

During an external review, an independent third party reviews your insurer’s decision.[16] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under North Carolina law, you are entitled to request an external review if your insurer denies your appeal on the basis that the services are not medically necessary, are experimental, or are cosmetic.[17]

You can also request an expedited external review in urgent situations at the same time you file a request for an expedited appeal.[18] Your situation is urgent if waiting would jeopardize your life or ability to function.

You should submit your request for an external review to the North Carolina Department of Insurance, Health Insurance Smart NC (“Smart NC”).[19] You must file your request within 120 days from the date that your insurer sent you its final decision.[20]

Information. You can find a copy of the request form here. You should include the following information with your request:

  • The name, address, telephone number, email address, and date of birth of the patient;
  • The name, address, telephone number, email address, and relationship to patient of the person filing the request (if different from the patient);
  • The name, practice type, address, and telephone number of the health care provider;
  • Information regarding the denied service;
  • The name of the insurance company;
  • The name of the insured individual;
  • The member identification number, group number, and name of employer, if applicable; and
  • The name and address of the treating physician and the telephone number and address of the health care practice.[21]

Requesting an expedited review. When you fill out the external review request form, be sure to indicate on page 2 of the form that you are requesting an expedited review.[22] You should include medical records and other supporting information from your health care provider explaining why your case should be expedited.[23]

Supporting documents. You should also include the following documentation:

  • A signed medical record release form (included in the external review request packet);
  • A copy of your insurance card;
  • A copy of the final denial letter from your health insurer;
  • A description of the disagreement; and
  • Any additional or new information and documentation not included with your request for an internal appeal or grievance.[24]

Submitting an external review. If you are requesting a standard external review, you can submit your request online here, fax it to (919) 807-6865, or mail it to the following address:

NC Department of Insurance
1201 Mail Service Center
Raleigh, NC 27699-1201[25]

The review process should take no more than 45 days from the date the review organization receives your request.[26] If you requested an expedited external review, the process should take no longer than three business days after receiving your request.[27]

If you are a North Carolina resident and you believe your insurer did something illegal or unethical, you can file a complaint with the North Carolina Department of Insurance, Health Insurance Smart NC Division (“Smart NC”).

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 Complainant’s relationship to the insured individual;
  • The name of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • The policy or group number, claim or certificate number, and date of loss;
  • The name of the insurance agent and adjuster in your case; and
  • The details of the complaint.

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of determination letters 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.[28]

How to submit. The complaint and supporting documents may be submitted online here or mailed to the following address:

North Carolina Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27669-1201[29]

Once your complaint is received, Smart NC will forward a copy of the complaint to your health insurer and require it to respond.[30] Smart NC will review your insurer’s response to determine whether its actions comply with all applicable laws, regulations, and policies. If the insurer has violated a law, regulation, or policy, Smart NC will require the company to take corrective action.[31]

You can contact the North Carolina Department of Insurance at (855) 408-1212. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 complete the following steps within 60 days of receiving your determination letter:

  • 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 appeal, if applicable. If waiting 30 days to receive your requested treatment would jeopardize your health, safety, or ability to regain function, you may request an expedited appeal. You should contact your insurer and ask for instructions on how to complete this step.
  • 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.

The internal appeals process should take a maximum of 30 days.[2] If your health care practitioner requests an expedited appeal, the process should take no more than 72 hours.[3]

During an impartial review (also known as an external review), an independent third party reviews your insurer’s decision.[4] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to request an impartial review if your insurer denies your internal appeal[5] You can request an expedited impartial review if one of the following circumstances applies:

  • You are hospitalized;
  • Your health care provider determines that your situation is urgent;
  • The treatment denial could seriously jeopardize your life, health, or ability to regain maximum function;
  • Your health care provider believes you would be subjected to severe pain that cannot otherwise be adequately managed without the requested treatment; or
  • The requested treatment is experimental or investigational and your health care provider certifies in writing that the treatment will be significantly less effective if not initiated promptly.[6]

You can request the expedited impartial review while you request the expedited internal appeal, if at least one of the above circumstances applies.[7] Please note that if you request an expedited appeal and the independent review entity issues a decision in favor of your insurer, you may be required to pay a $25 fee.

Request to Insurer for Impartial Appeal. You should send your request for an additional impartial appeal to your insurer if your insurer denied your claim because it deemed your requested treatment or services not medically necessary or experimental/investigational.[8]

The appeal must be made  within four months of receiving your upheld denial letter and you should  send the following documents to the insurer:

  • A written request for an impartial review; and
  • A signed medical records release form, which your insurer should have provided to you with your denial letter.[9]

Your insurer will then send your request to an independent review entity. The insurer will notify you when the external impartial medical review is assigned to the entity.[10]

Request to the Department. If your insurer denied your claim because your plan (1) placed limitations on the requested treatment or services; or (2) did not cover your requested treatment or services, you should submit a request for an impartial review to the Kentucky Department of Insurance, Health and Life Division (“Department”). You should  send the following documents to the Department:

  • A written request for an impartial appeal;
  • A copy of the denial letter from your insurer; and
  • A statement containing the reason you believe coverage should be provided.[11]

You should mail these documents to the following address:

Kentucky Department of Insurance
Health and Life Division
Attn: Coverage Denial Coordinator
P.O. Box 517
Frankfort, KY 40602[12]

The Coverage Denial Coordinator will request information from your insurer and determine whether the service, treatment, drug, or device meets one of the following:

  • Is specifically excluded under your plan and the insurer’s denial was correct;
  • Is covered and will instruct your insurer to pay the claim; or
  • Requires the resolution of a medical issue and will instruct your insurer to either cover the claim or give you the opportunity to request an external review.[13]

Request to Consumer Protection Division for Impartial Review. If your health insurer denied your claim because you failed to follow the requirements or procedures set out in your insurance benefits handbook, or you have a general complaint, you should submit a request for impartial appeal to the Kentucky Department of Insurance, Consumer Protection Division. You can submit your request by completing an online form here or mailing your request to the following address:

Kentucky Department of Insurance
Consumer Protection Division
P.O. Box 517
Frankfort, KY 40602[14]

In your request, you should state your reason for appealing your insurer’s determination and submit any copies of documents that support your position.

The impartial review process should take no more than 45 days. If you requested an expedited impartial review, the process should take no longer than 72 hours after your request is received.[15]

If you are a Kentucky resident and your insurer denies your coverage after the impartial appeal process, you can file a complaint with the Kentucky Department of Insurance (“Department”).

Complaint information. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • Policy number, group number, and the name and address of the agent/adjuster; and
  • The details of 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 impartial 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.[16]

How to submit. The complaint may be submitted online here, faxed to (502) 564-2728, or mailed to:

Kentucky Public Protection Cabinet
Department of Insurance
P.O. Box 517
Frankfort, KY 40602-0517[17]

Once the Department receives your complaint, it will send a copy to your insurer who then has 15 calendar days to respond. A typical case should be resolved within 30 days.[18]

You can contact the Kentucky Department of Insurance at (800) 595-6053 (for Kentucky residents only) or (502) 564-6034 and ask to speak with a Consumer Complaint Investigator. The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.

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 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 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.

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.[2]

During 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 West Virginia law, you are entitled to request an external review if your insurer:

  • Denies your internal appeal; or
  • Does not provide you with a decision on your internal appeal within the required timeframe.[4]

You can also request an expedited external review if your life or health would be jeopardized by waiting 30 to 60 days.[5] You may request an expedited external review simultaneously with an internal appeal.[6]

You should submit your request for external review to the West Virginia Offices of the Insurance Commissioner (“Offices”) within 180 days from when your insurer sent you the final decision.[7] You can find a copy of the Independent External Review of Healthcare Decision  form here.

Information. You should include the following information with your request:

  • The name, address, email address, and telephone number of the insured;
  • The patient’s name;
  • The name and telephone number of your employer;
  • The name, address, and telephone number of the insurance company;
  • The name of the contact person at your insurance company;
  • The name, type of provider, address, and telephone number of your health care provider;
  • A description of the dispute; and
  • An “Expedited Appeal Certification by Treating Healthcare Provider” form found in the external review packet (This form is for expedited external review requests only).[8]

Supporting documents. You should include the following documents with your request:

  • A signed medical records release form (included in the external review request packet);
  • A copy of your insurance card or other evidence of insurance coverage;
  • A copy of your denial letter;
  • A copy of your certificate of coverage or insurance policy benefit booklet; and
  • Any medical records, statements from your health care provider, and any additional or new information and documentation you’d like the external review organization to review.[9]

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request to the following address:

Independent External Review
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540[10]

How to submit an expedited external review request. If you are requesting an expedited external review, you should call (304) 558-3386 to ask for instructions on the quickest way to submit your request.[11]

The external review process should take no more than 45 days after the Offices of the Insurance Commissioner receives your request.[12] If you request an expedited external review, the process should no longer than 72 hours after your request is received.[13]

If you are a West Virginia resident and your insurer denies your coverage after the external review process, you can file a complaint with the West Virginia Offices of the Insurance Commissioner Consumer Services Division (“Division”).

Complaint information. You can find a copy of the complaint form here. 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 patient and name of the insured, if different than the Complainant;
  • The names of other parties involved in the claim;
  • The name of insurance company;
  • The type of coverage, policy number, claim number, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[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 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.[15]

How to submit. The complaint and supporting documents can be faxed to (304) 558-4965 or mailed to the following address:

Consumer Services Division
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540[16]

Once the Division receives your complaint, it will assign it to an insurance specialist who will send an acknowledgement letter to you. It will contact the insurance company, who then has 15 working days to respond. After the response is received, the specialist will review the insurer’s response and any documents the insurer has submitted with the response (such as a copy of the policy or certificate of insurance) to determine if the insurer is handling your claim appropriately. If no violations are evident, the specialist will notify you that he or she is closing the complaint. If the specialist determines that there may have been a violation, the complaint is then turned over to the legal department for further action.

You can contact the West Virginia Offices of the Insurance Commissioner at (888) 879-9842.  The Offices are open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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 urgent care appeal, if applicable. You can request an urgent care appeal if you require urgent care.[2] You require urgent care if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function or you would be in severe pain that could not be adequately managed without the requested service or treatment.[3] You can submit your request for an urgent care appeal either over the phone or in writing to your health insurer.[4]

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.[5] If you have requested an urgent care appeal, the process should take no more than 72 hours to complete, unless there is vital information missing.[6]

During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Virginia law, you are entitled to request an external review in the following circumstances:

  • If your insurer denies your coverage after an internal appeal; or
  • Your insurer has not responded to your internal appeal request within the required 30 or 60 day timeframes and you have not agreed to extend or waive the time.[8]

You can also request an expedited external review if your medical situation is urgent. You can file a request for an expedited external review while you file a request for an urgent care appeal.[9]

You should submit your request for an external review to the Virginia Bureau of Insurance (“Bureau”) within 120 days from the date that your insurer sent you the final decision.[10]

Information. You can find a copy of the request Form 216-A here. You should include the following information with your request:

  • The name of the applicant;
  • The name, address, email address, telephone number, and date of birth of the covered person;
  • The name, address, and telephone number of the insurance company;
  • Insurance identification number and insurance claim or reference number;
  • Your employer’s name and telephone number;
  • The name and address of your treating health care provider;
  • The name and telephone number of the contact person at your health care provider’s office; and
  • The reason for the denial.[11]

If you are requested an expedited external review, your health care provider must complete a Form 216-C “Physician Certification Expedited External Review Request” certifying that a delay in treatment of your condition would seriously jeopardize your life, health, or ability to regain function. A copy of the Form 216-C can be found here. If your claim involves emergency services and you have not yet been discharged from an inpatient facility (such as a hospital), you do not need to complete Form 216-C though.[12]

Supporting document. You should include the following documents with your request:

  • A signed medical records release form (included in request packet);
  • A copy of your insurance card;
  • A copy of the final determination letter from your insurance company; and
  • Any additional or new information and documentation not included with your request for an internal appeal.[13]

Submitting an external review. You can submit your request by fax to (804) 371-9915, by email to [email protected], or by mail to the following address:

State Corporation Commission
Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218[14]

The independent external review organization should provide a decision within 45 days of receipt of the request for external review.[15] The entire external review process should take no more than 60 days.[16] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[17]

If you are a Virginia resident and have completed the internal and external review processes, you can file a complaint with the Bureau.

Complaint information. Your complaint should include the following information:

  • The type of insurance;
  • The name, address, email address, and telephone number of the patient;
  • The name, address, email address, telephone number, and relationship to patient of the person filing the complaint (“Complainant”);
  • The name of the insurance company;
  • Policy number, certificate number, or identification number; and
  • A description of the issue.

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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[18]

How to submit. The complaint may be submitted by fax to (804) 371-9944, or by mail to the following address:

State Corporation Commission
Bureau of Insurance
Life and Health Division
P.O. Box 1157
Richmond, VA 23218[19]

The Bureau will send a copy of the complaint to your health insurer and attempt to resolve the issue with them.[20] It may take up to 45 days or longer for your claim to be resolved, depending on the complexity of the issue.[21] The Bureau may require the insurance company to comply with the policy (in other words, make the insurer cover the requested treatment or service), issue a citation, or fine the company.

You can contact the Virginia Bureau of Insurance at (804) 371-9691, (800) 552-7945 (in-state), or (877) 310-6560. The Bureau is open from 8:15 a.m. to 5:00 p.m., Monday through Friday.

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 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.[2]
  • 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.

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.[3]

A. Expedited Internal Appeals for Increased Health Risks

You can request an expedited internal appeal if:

  • You are currently receiving health care services and you could experience a significantly increased health risk if your insurer denied those services; or
  • Your insurer denied a treatment referral, service, procedure, or other health care service and the denial significantly increases the risk to your health.[4]

To obtain an expedited internal appeal, contact your insurer and request an expedited internal appeal either orally or in writing, depending on your health insurer’s policy.[5] Your determination letter should provide specific instruction about how to request the expedited internal appeal.

Once you request the appeal, your health insurer should notify you within 24 hours to either (1) ask for any additional information it needs to evaluate the appeal; or (2) to provide you with a decision. If the insurer asked for additional information, it should provide you with a decision within 24 hours of receiving the additional information.[6]

B. Expedited External Reviews for Urgent Situations

In urgent situations, you can skip the internal and expedited internal appeals processes and request an expedited external review instead. Your situation is urgent in the following circumstances:

  • You have a medical condition and waiting 48 hours for treatment would jeopardize your life, health, or your ability to regain function; or
  • Your insurer deems your requested treatment “experimental” or “investigational,” and your health care provider certifies that the treatment would be significantly less effective if it is delayed.[7]

During an external review, an independent third party reviews your insurer’s decision.[8] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal and did not receive a response within 30 days (if you did not receive the requested treatment or service) or 60 days (if the insurer denied payment for a treatment or service you did receive);[9]
  • You requested an expedited internal appeal and did not receive a response within 48 hours;
  • You received a denial letter after requesting an internal appeal or expedited internal appeal; or
  • Your insurer still denies you coverage after you requested an internal appeal.

To obtain an external review or expedited external review, you should complete the following steps:

Obtain documents. Collect the following documents for your external review request:

  • The external review request form packet (click here). You should use this form for both standard and expedited external reviews;
  • Release of medical records form, which is included in the external review request form packet;
  • Copy of your insurance card;
  • Copies of all determination letters and any other information that your insurer sent to you;
  • Medical records related to the condition for which you are seeking treatment;
  • Any peer review literature or clinical studies related to your requested treatment; and
  • Any additional information from your health care provider that you want the independent review organization to consider.[10]

Prepare your request. Complete the external review request form and medical release form. Be sure to include the following information:

  • The name, address, telephone number, and email address of the person filing the request (“applicant”);
  • Applicant’s relationship to the patient;
  • The name, address, telephone number, and email address of the patient, if different than applicant;
  • The name of the insurance company and name of the insured person;
  • The primary insured person’s identification number and patient identification number;
  • Whether the health plan is an individual plan, group plan through employer (and include employer’s name), or a group plan through a plan sponsor (and include the sponsor’s name);
  • The name, address, telephone number, and email address of the health care provider and name of the contact person at the provider’s office;
  • The reason for the appeal; and
  • A description of the treatment, service, drug, or procedure being denied, the date of service, and the date of denial.[11]

Submit your request. Submit your request for an external review or expedited external review and supplemental documentation within four months from the date that your insurer sent you the last determination letter. You can also fax your materials to (217) 557-8945 or email them to [email protected]. You can also mail your request to:

Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Request
320 W. Washington Street
Springfield, IL 62767[12]

After the review organization receives all of the necessary information relating to your claim, you should receive a response within the following timeframes:

  • No more than 45 days for standard external reviews;
  • No more than 72 hours for expedited external reviews; and
  • No more than seven calendar days for requested experimental or investigational treatments or services.[13]

If you are an Illinois resident and your insurer denies your coverage after the external review process or your insurer determines your claim is not eligible for external review, you can file a complaint with the Illinois Department of Insurance (“Department”).

Click here for the complaint form. 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;
  • The insured’s individual identification number;
  • The name of the employer or group if it’s a group plan;
  • Claim number and date of service; and
  • The details of the complaint.

You can attach supporting documents to complaints submitted online or you can fax or mail supporting information.[14] You should submit the following documents as supporting information:

  • 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

The complaint may be submitted online here, faxed to (217) 558-2083, or mailed to:[16]

Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767

Once the Department receives your complaint, it will be assigned a file number. A copy of the complaint will be sent to your health insurer, who has 21 days to respond. An analyst will review the complaint and the insurance company’s response. The investigation will take between four and six weeks, and you will be advised of the decision.[17]

You can contact the Illinois Department of Insurance Customer Assistance Hotline at (866) 445-5364. The Department is open from 8:00 a.m. to 8:00 p.m. Monday through Saturday.

If your insurer denies your claim, you have the right to an internal appeal, known in Indiana as an “internal grievance.”[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file an internal grievance, 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.[2]
  • 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.

The internal grievance process should take a maximum of 45 days.[3] You can skip the internal grievance process and request an expedited external grievance review in urgent situations.[4] Your situation is urgent if waiting 45 days would seriously jeopardize your life or your ability to regain function. 

If your insurer still denies you coverage after you filed an internal grievance, you can request an external grievance review of your insurer’s decision. If your situation is urgent, you can request an expedited external grievance review.[5] During an external grievance review, an independent third party reviews your insurer’s decision.[6]

You should file your request for a standard or an expedited external grievance review with your health insurer within 120 days of the most recent determination letter.[7] Your insurer must provide you with information on how to submit your request.[8] Be sure to carefully read your insurance policy and any documentation you received with your determination letter to ensure that you follow your insurer’s instructions closely.[9]

Once your insurer receives your request, it will submit your materials to an independent review organization. An independent reviewer will conduct an investigation and render a decision.[10]

The external grievance review process should take no more than 15 days after the external grievance is filed.[11] If you request an expedited external grievance review, the process should take no longer than 72 hours after your request is received.[12]

If you are an Indiana resident and you have completed the internal appeal and external review processes but still lack access to a treatment, you can file a complaint with the Indiana Department of Insurance (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of the insured person;
  • The name and address of insurance company;
  • The state where the insurance plan was purchased;
  • Policy number and claim number;
  • If a group policy, the name and address of the employer; and
  • The details of the complaint.[13]

You must also submit the following supporting documents:[14]

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters 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 practitioner;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

The complaint may be submitted online here, faxed to (317) 234-2103, or mailed to the following address:

Indiana Department of Insurance
Consumer Services Division
311 W. Washington Street, Suite 300
Indianapolis, IN 46204-2787[16]

The Department will process your complaint within 72 hours.[17] You will receive a confirmation letter that includes your problem report number and the name of the Consumer Consultant handling your case. The Consultant will send a copy of the complaint to your health insurer. Your insurer must respond to the complaint within 20 days. The Department will then provide you with a decision.[18] If the Department determines that insurer violated a law, regulation, or policy, the Department may take corrective action against the insurer, including fines or a lawsuit.[19]

You can contact the Indiana Department of Insurance at (800) 622-4461 or (317) 232-2426. The Department if open from 8:00 a.m. to 4:15 p.m. Monday through Friday.

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 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.[2] You should contact your health insurer to request an expedited internal appeal.[3]
  • 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.[4]

During an external review, an independent third party reviews your insurer’s decision.[8] 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.[9]

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.[10]

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.[5]

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.[6]

You should receive a decision on an expedited internal appeal within 72 hours of your insurer receiving your request.[7]

You should submit your request for an external review to your health insurer in writing by mail, fax, or email.[11] 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.[12]

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.[13] Otherwise, your insurer will send your request to an external review organization.[14]

The external review process should take no more than 30 days from the date the external review organization receives your request.[15] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[16]

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.[17]

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[18]

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.[19] 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.

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 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 claim was denied 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. 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. You can request an expedited internal appeal if waiting 30 to 60 days for the requested treatment or service would jeopardize your life, health, or ability to regain function or if your health insurer has refused coverage for an admission or continued stay at a health care facility where you have not yet been discharged.[2] If you believe you qualify for an expedited internal appeal, you should contact your insurer and ask for instruction on how to request one.
  • 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.

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.[3] An expedited internal review must be completed within 72 hours of receiving the request.[4]

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Pennsylvania law, you are entitled to request an external review if your insurer denies your internal appeal.

You can also request an expedited external review if:

  • Your medical situation is urgent and waiting would jeopardize your life or ability to function; or
  • Your health insurer has denied covered for an admission or continued stay at a health care facility where you have not been discharged.[6]

 You can request an expedited external review at the same time that you request an expedited internal appeal.[7]

You should submit your request for an external review to your health insurer within four months from the date that your insurer sent you the final decision.[8] Upon receipt of your request for external review, your health insurer will assign your case to an external review organization.[9]

Once your request is assigned to an external review organization, you have 10 days to submit supporting documentation to the external review organization. You should include documentation from your health care provider supporting why he or she prescribed the service or treatment and any other new information and documentation that you did not include with your previous request for an internal appeal.[10] Your insurer will notify you where to send the information.[11]

The external review process should take no more than 45 days from the date the external review organization receives your request.[12] If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[13]

If you are a Pennsylvania resident and your claim is denied after the external review process, you can submit a complain to either the Pennsylvania Insurance Department (“Department”) or Pennsylvania Attorney General’s Office (“Office”). Both the Department and the Office handle complaints regarding health insurance companies involving claim disputes and denials of service, so you can file your complaint with either agency. You should not file a complaint with both agencies at the same time.

If you are a Pennsylvania resident and your claim is denied after the external review process, you can file a complaint with the Department.

Complaint information. A copy of the complaint packet can be found here. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person making the complaint (“Complainant”);
  • The name of the insured, if different than the Complainant;
  • Insurance identification number;
  • The type of insurance;
  • The type of problem;
  • The name of the insurance company;
  • Policy number, claim number, and date of loss;
  • The state in which the policy was sold;
  • Brief description of the issue; and
  • What you consider to be a fair resolution.[14]

Supporting documents. You should submit the following supporting documents as with your complaint:

  • A signed medical record release form (included with the complaint packet);
  • A copy of your insurance card;
  • Copies of coverage determination letters 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

How to submit. The complaint may be submitted online here, by fax to (717) 787-8585, or by mail to the following address:

Pennsylvania Insurance Department
Bureau of Consumer Services
Room 1209, Strawberry Square
Harrisburg, PA 17120[16]

Upon submitting your complaint, you will receive a complaint identification number.[17] The Department will forward a copy of your complaint to your health insurer, who has 15 days to respond. The process generally takes up to a month to complete. In many situations, the insurance company will agree to reverse or reprocess the claim.

If you are a Pennsylvania resident and your claim is denied after the external review process, you can file a complaint with the Office. A copy of the complaint packet can be found here.

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 person on whose behalf complaint is being filed, if different than the Complainant;
  • The name of the insured;
  • The name, address, and telephone number of insurance company;
  • The policy number, group number, and type of insurance;
  • The name, date of birth, and relationship to insured of the patient;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[18]

Supporting document. You should submit the following supporting documents with your complaint:

  • A signed medical record release form (included with the complaint packet)
  • A copy of your insurance card;
  • Copies of determination letters 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[19]

How to submit. The complaint may be submitted online here, by email to [email protected], or by mail to the following address:

Office of Attorney General
Health Care Section
14th Floor, Strawberry Square
Harrisburg, PA 17120[20]

Once the Office receives your complaint, a Health Care Section agent will determine if the Office is the most appropriate agency to address your concern.[21] If so, the agent will forward a copy of your complaint to your health insurer. Your insurer must respond within 15 business days.[22] After reviewing all documentation, the agent will send you a decision.  You should expect the process to take a minimum of 30 days.[23] In many cases, the insurance company will agree to reverse or reprocess the claim.

If the Health Care Section is not the appropriate agency to handle your complaint, the agent will forward it to the appropriate agency and advise you where it has been sent.[24] If your complaint involves an allegation of fraud or possible criminal activity on the part of the insurer, your complaint may be sent to the Insurance Fraud Section or the Criminal Prosecutions Section or another state or federal agency, depending on the facts of your case.

You can contact the Pennsylvania Attorney General’s Office, Health Care Section at (717) 705-6938 or (877) 888-4877. The Office is open from 8:30 a.m. to 5:00 p.m. Monday through Friday.

You can contact the Pennsylvania Insurance Department at (877) 881-6388. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

If your insurer denies your claim, you have the right to file a grievance.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 file your grievance.

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 a 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 file a grievance and draft a strong appeal letter.

Submit the appeal request. You or someone in your health care provider’s office should submit the grievance 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 grievance, if applicable. You can file an expedited grievance if one of the following circumstances applies:

  • Waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your pain cannot adequately be managed without the requested service or treatment; or
  • Your physician determines that your grievance should be treated as an expedited grievance.[2]

You can file a request for an expedited grievance in the same way as you would file for a standard grievance.

The grievance process should take a maximum of 30 days, although your insurance company can extend that time period for an additional 30 days.[3] An expedited grievance must be resolved within 72 hours.[4]

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say whether to approve a treatment or pay a claim. Under Wisconsin law, you are entitled to request an external review if your insurer denies your coverage after a grievance.[6]

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function. You should contact your insurer and ask whether you can also skip the grievance process altogether when requesting an expedited external review.

Your health insurer should have provided you with instructions on how to request an external review with your final adverse determination letter.[7] You should follow those instructions closely. Be sure to submit your request for an external review to your insurer within four months from receiving the final decision letter.[8] You should include any new information and documentation that you did not include when you filed your grievance.

For expedited external review requests, you should submit your request to your health insurer and the independent review organization simultaneously.[9] Your health insurer is required to provide you with information on how to file this request.[10]

Once your request is received, your insurer will send the request and all relevant medical records and documentation to an independent review organization.[11]

The external review process should take no more than 40 days from the date you submit your request.[12] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[13]

If you are a Wisconsin resident and your claim is denied after the external review process, you can file a complaint with the Wisconsin Office of the Commissioner of Insurance (“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 of the insured individual, if different than the Complainant;
  • The name of your employer;
  • The name of the insurance company;
  • The state where the insurance plan was purchased;
  • The policy/certificate number, claim number, type of insurance, and date of loss;
  • 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.[14]

How to submit. The complaint and supporting documents may be submitted online here, faxed to (608) 264-8115, or mailed to the following address:

Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873

If you are sending your complaint by FedEx, UPS, or overnight mail, you should send it to the following address:

Office of the Commissioner of Insurance

125 South Webster Street
Madison, WI 53707-3474[15]

The Office will send your complaint to your health insurer and require it to provide an explanation for its actions. Your insurer will have 20 days to respond. The Office will then review the health insurer’s response and require it to either fix the problem or work with you and your health insurer to resolve the issue.[16] The Office may require the insurer to comply with the policy, issue a citation, or fine the company.

You can contact the Wisconsin Office of the Commissioner of Insurance at (800) 236-8517 (in-state) or (608) 266-0103. The Office is open from 7:45 a.m. to 4:30 p.m., Monday through Friday.

If your insurer denies your claim, you have the right to submit an internal grievance.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 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 a 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 internal grievance, if applicable. You can also submit an expedited internal grievance in writing to your health insurer. To qualify for an expedited internal grievance, your health care provider must certify to your insurer, over the phone or in writing, that the time frame for resolving a standard internal grievance would seriously jeopardize your life, health, or ability to regain function.[2]
  • 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.

The internal grievance process should take a maximum of 30 calendar days plus an additional ten business days if your insurer has not received requested information from a health care provider or health care facility.[3] The expedited grievance process should take no longer than 72 hours after the insurer receives your expedited grievance request.[4]

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. Under Michigan law, you are entitled to an external review if:

  • Your insurer denies, reduces, or terminates your coverage; and
  • You have completed the internal grievance process or your insurer does not provide you with a decision within the allotted time.[5]

You may also request an expedited external review if your medical situation is urgent and waiting 35 days would jeopardize your life or ability to function. You may request an expedited external review while you request an expedited internal grievance.[6]

You should submit your request for external review to the Michigan Department of Insurance and Financial Services (“Department”) within 60 days from the date that your insurer sent you the final decision. If you are requesting an expedited external review, you must submit your request within ten days of receipt of the most recent decision letter.[7]

Information. You can find a copy of the external review request form here. Your request should include the following information:

  • The name, address, telephone number, and relationship to patient of the person filing the request;
  • The patient’s name;
  • The name of the insured person;
  • The name of your health insurer;
  • The policy number, group number, and claim number, if applicable;
  • Dates service was received or requested;
  • The name of the physician and medical facility involved;
  • A description of the problem involved.[8]

Supporting document. You should also include the following supporting documents with your request:

  • A copy of the final adverse determination letter;
  • Copies of bills, explanations of benefits, and medical records related to the request;
  • Copies of correspondence between you and the health insurer;
  • Statements from doctors; and
  • Any research material that supports your position.[9]

Where to submit for a standard external review. You can submit the request and supporting documents by fax to (517) 284-8838, by email to [email protected], or by mail to:[10]

DIFS-Office of General Counsel-Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720

Where to submit for an expedited external review. If you are requesting an expedited external review, you should submit your request and supporting documents by courier or delivery to the following address:

DIFS-Office of General Counsel-Appeals Section
530 W. Allegan Street, 7th Floor
Lansing, MI 48933[11]

If you have any questions, you can call the Department at (877) 999-6442.

If your case involves a decision regarding provisions of your insurance contract or policy, the review will be conducted by the Director of the Department. If your case involves a question of medical necessity, it will be referred to an independent review organization for review.[12]

  • Issue with your policy. If your case involves a decision regarding part of your insurance contract or policy, the Department has 14 calendar days to give you a decision.
  • Question of medical necessity. If the medical necessity of your treatment is at issue, the Department has 21 days to provide you with a decision.[13]
  • Expedited external review. If you requested an expedited external review, the Department has 72 hours to provide you with a decision.[14]

If you are a Michigan resident and 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 date of the healthcare service;
  • The name of insurance company and name of agent or agency, if applicable;
  • The policy number, group contract number, and name of group/employer, if applicable;
  • The reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

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.[15]

How to submit. You can submit the complaint online here, faxed to (517) 284-8837, emailed to [email protected], or mailed to the following address:[16]

DIFS – Office of Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720

Once the Department receives your complaint, it will forward a copy to your health insurer and ask for a response. For policies issued before July 1, 2016, the insurer has 35 days to respond to the complaint. For policies issued after July 1, 2016, the insurer has 60 days to respond to the complaint. The Department will complete an investigation and provide you with a decision.[17] The Department may force the insurer to comply with the policy, issue a citation, or fine the insurer if it finds the insurer has violated a state law or regulation.

You can contact the Michigan Department of Insurance and Financial Services at (877) 999-6442. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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 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. You can request an expedited internal appeal if your insurer denied you continued or extended health care services, procedures, or treatments for which you are undergoing or home health services following your discharge from an inpatient hospital admission.[2] You can also request an expedited internal appeal if your health care provider believes that your case requires an immediate appeal. You should have received instructions for requesting an expedited appeal with your determination letter.[3] If you did not, contact your insurer and request instructions.
  • 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.
  • Complete second level of internal appeal (optional). Your health insurer may offer a second level of internal appeal which is voluntary. You are not required to participate in the second level under New York law.[4] Your health insurer should notify you of the option of filing a second level internal appeal, and what you need to do to request a second level appeal, including any additional documentation you should submit.[5]

The internal appeal process, including both first level and second level appeals, should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days, including both first level and second level appeals, if you have received the service or treatment but are waiting for reimbursement.[6] An expedited internal appeal should take no longer than 72 hours to receive a decision.[7]

During an external review, an independent third party reviews your insurer’s decision.[8] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New York law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal.

You can also request an expedited external review if one of the following circumstances applies:

  • The denial concerns an admission, availability of care, continued stay, or health care service for which you received emergency services and have not yet been discharged from the hospital;
  • Waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function; or
  • If a delay in treatment would pose an imminent threat to your health.[9]

You should submit your request for external review to the New York Department of Financial Services (“Department”).[10] You must submit your request within four months from the date of the determination letter from the first level of appeal even if your health insurer offers a second level of internal appeal.[11]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • The name of the applicant;
  • The name, address, telephone number, and email address of the patient;
  • The name of the insurance company;
  • The name, address, and telephone number of the patient’s healthcare provider;
  • Reason for health plan denial; and
  • Description of complaint and dates of service.[12]

Supporting documents. You should submit any new information and documentation not included with your request for an internal appeal with your request for an external review. If you are requesting an expedited review, you should also attach a Physician Attestation form, which is including in the external review request packet.[13]

Filing fee. You must pay a $25 filing fee by check or money order made payable to your health insurer, if your health insurer requires such a fee.[14] The fee can be waived if you are covered by Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. If you qualify for the wavier or your appeal is successful, your fee will be refunded to you.[15]

Submitting a standard external request. You can submit the request to the Department by fax to (800) 332-2729 or by certified or registered mail to the following address:

Department of Financial Services
P.O. Box 7209
Albany, NY 12224[16]

Submitting an expedited review. If you are requesting an expedited external review, you must contact the Department of Financial Services at (888) 990-3991.[17]

The external review process should take no more than 30 days from the date the external appeal agent receives your request. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[18]

If you are a New York resident and you believe your insurer did something illegal or unethical, 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 type of insurance, type of claim, policy number, claim number, and date of loss or service;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[19]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage determination letters 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[20]

How to submit. The complaint may be submitted online, faxed to (212) 480-6282, or mailed to the following address:

Department of Financial Services
Consumer Assistance Unit
One Commerce Plaza
Albany, NY 12257 [21]

The Department will review your complaint to determine if the Department can assist you. You will be notified if the Department has decided not to review your case. Otherwise, the Department will attempt to resolve your complaint with your health insurer.[22] It will investigate to determine if your insurer is breaking with state law or committing fraud.[23] The Department can force the insurer to comply with your insurance policy, issue citations, or fine the insurer. This process can take anywhere from a few weeks to a few months.

You can contact the New York Department of Financial Services at (212) 480-6400 or (800) 342-3736. The Department is open from 8:30 a.m. to 4:30 p.m. Monday through Friday.

If your insurer denies your claim for a medical reason, then your health care provider may request a reconsideration of the denial. You are not responsible for submitting the request. The request must be completed by your insurer within one working day after the insurer receives the request.[2] If your health care provider either does not request a reconsideration or is not successful, you have the right to two levels of internal appeals and possibly an independent external review.[3]

If your insurer denies your claim, you have the right to a first level 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 appeal, if applicable. If your health care provider believes that you require medical care sooner than it would take to go through the regular first level and second level internal appeals processes, you or your health care provider can submit a request to your health insurer for an expedited internal appeal.[4] You qualify for an expedited internal appeal if a denial of the requested treatment within 45 days would seriously jeopardize your life, health, or ability to function.[5] It should be noted that expedited internal appeals are not available for retrospective denials.[6]
  • 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. 

If the first level internal appeal is not successful, you should submit a request to your health insurer for a second level internal appeal. During the second level internal appeal, your case is reviewed by a panel of insurance company personnel.[7] You may ask for a hearing as part of the second level internal appeal, and you and your health care provider can participate in the hearing either in person or by telephone.[8]

The first level internal appeals process should take a maximum of 30 days from the date your insurance company receives your request for an internal appeal.[9] If you request a hearing during the second level appeal, your health insurer must schedule the hearing within 45 days, and the panel has five days to make their decision. If there is no hearing, your health insurer must notify you of its decision within 30 days.[10] If you requested an expedited internal review, the decision should be rendered within 72 hours after your request is received.[11]

If your insurer denies your coverage after completing the first and second level internal appeals processes, you are entitled by law to request an external review from an independent third party. This means your insurer no longer has the final say over whether to approve a treatment or pay a claim.[12]

You can apply for an expedited external review if you requested an expedited internal appeal and your request was denied.[13]

You should call or write to the Maine Bureau of Insurance (“Bureau”) to request an external review within 12 months from the date that your insurer denied the second level internal appeal.[14] You can reach the Bureau at (207) 624-7475 or (800) 300-5000 (Maine only) or by mail at:

Consumer Health Care Division
Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333.[15]

If you are requesting an expedited external review, you should immediately contact the Maine Bureau of Insurance (“Bureau”) at (207) 624-8475 or (800) 300-5000 to make your request.[16]

If the Bureau determines that you qualify for an external review, it will send you a packet of forms, including an authorization and contact sheet.[17] You should complete the forms and send them to the Bureau at the above address, along with a copy of your final determination letter and any new information and documentation not included in the internal appeals.[18].

The external review process should take no more than 30 days from the date the external review organization receives the request.[19] If you request an expedited external review, the process should take no longer than four business days after your request is received.[20]

If you are a Maine resident, you can file a complaint with the Bureau at any time during the appeals process. 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 your employer if your health insurance is through your employer;
  • The name, address, and telephone number of the insurance company;
  • The policy, certificate, or identification number and claim number; and
  • The details of the complaint.

You can find a copy of the complaint form here. You should also submit the following supporting documents:

  • A signed medical records release form (included in the online application);
  • A copy of your insurance card;
  • Any correspondence, including emails, notices, explanations of benefits, and any other communications between you and your health insurer related to the complaint;
  • Records explaining how claim payments were calculated;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[21]

The complaint may be submitted online here, faxed to (207) 624-8599, or mailed to:

Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333

Your complaint will be assigned to a claims investigator. The investigator will contact your insurer and request a response. The health insurer has 14 days to respond, but may request an extension. It usually takes a minimum of 30 days to complete an investigation.[22] The Bureau can force the health insurer to comply with the policy, issue a citation, or fine the insurer for violations of law or regulation.

You can contact the Bureau at (800) 300-5000 or (207) 624-8475. The Bureau is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

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 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.[2]
  • 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.

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.[3]

You can skip the internal appeals process and request an external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

To request an expedited external review, call the U.S. Department of Health and Human Services at (888) 866-6205 or by complete an external review request form, which can be found here. You can submit the completed form by faxing it to (888) 866-6190) or by mailing it to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.[5]

If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[6] During an external review an independent third party reviews your insurer’s decision.[7]

Florida participates in the external review process administered by the U.S. Department of Health and Human Services. You can request an external review form by calling (800) 866-6205. You should include any new information or documentation.

Once you complete the form, you can fax it to (888) 866-6190 or mail it to:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.[8]

You must request an exteral review within 60 days from the date that your insurer sent you the final decision.

The external review process should take no more than 60 days. If you request an expedited external review, the process should take no longer than four business days after your request is received.[9]

If you are Florida resident and your insurer denies your coverage after the external review process, you can file a complaint with the Florida Division of Consumer Services (“Division”). You should have the following information available when filing your complaint:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The state where the insurance plan was purchased;
  • Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.

You should submit the following documents as supporting information:

  • 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.[10]

You may submit the complaint electronically along with supporting documents here. Alternatively, you can call in your complaint to (877) 693-5236 (in-state) or (850) 413-3089 (out-of-state). You can also email your complaint and supporting documents to [email protected].[11]

An investigator for the Division will contact your health insurer regarding your complaint. The investigator should resolve the complaint within 30 days.[12]

You can contact the Florida Division of Consumer Services at (877) 693-5236 (in-state) or (850) 413-3089 (out-of-state). Division specialists are available to answer your questions 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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.[2]
  • 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.

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.[3]

You can skip the internal appeals process and request an external review in urgent situations.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[5] During an external review, an independent third party reviews your insurer’s decision.[6]

If you reside in Alaska, you should submit your request for an external review to your health insurer.[7] Your health insurer will submit your request to a qualified external review agency for consideration.[8] You will have an opportunity to send any documentation that your insurance company does not already have, including, but not limited to, additional medical records, the opinion of your treating physician, and any peer-reviewed studies applicable to your situation.[9] The external appeal agency will consider the following in making a decision in your case:

  • Guidelines or standards used by the health insurer in making its original decision to deny services;
  • Any personal health and medical information related to the condition for which treatment or medication has been denied to you;
  • Your physician or health care provider’s opinion; and
  • Your health insurance policy.[10]

The external appeal agency may also consider the following in making its decision:

  • Medical studies related to your condition;
  • The results of professional consensus conferences;
  • Practice and treatment guidelines;
  • Government-issued coverage and treatment policies;
  • Generally accepted principles of medical practice;
  • Expert opinions;
  • Peer reviews conducted by your health insurer; and
  • The community standard of care.[11]

You must file your written request for an external review within 60 days from the date that your insurer sent you the final decision.

The external appeal agency should respond to you within 21 business days.[12] If you request an expedited external review, then the agency should respond to your request within 72 hours after your request is received.[13]

If your insurer denies your coverage after the external review process, you can file a complaint with the Alaska Division of Insurance (“Division”).

Your complaint should include the following information:

  • The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
  • What you consider to be a fair resolution.

You should also submit the following documents as supporting information:

  • 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.[14]

The complaint may be submitted online at: https://sbs-ak.naic.org/Lion-Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanishVersion=N, faxed to (907) 269-7910, or mailed to the following address:

Alaska Division of Insurance
550 West 7th Avenue, Suite 1560
Anchorage, AK 99501-3567[15]

Within two weeks of filing your complaint, the Division should send you a letter with a file number and the name of the specialist assigned to investigate your complaint. The specialist will then contact your health insurer and attempt to resolve the issue.[16]

You can contact the Alaska Division of Insurance, Consumer Services section at (800) 467-8785 (calling from within the state) or (907) 269-7900 (calling from outside the state). The Division is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

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 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 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 appeal, if applicable. You may request an expedited internal appeal if waiting 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain functioning, or would subject you to severe pain that could not be adequately managed.[2] If you believe you qualify for an expedited appeal, you should contact your insurer and ask for instructions on how to request one.[3]
  • 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.

The internal appeals process should take a maximum of 60 days.[4] An expedited internal appeal should take no more than 72 hours after the request is submitted.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Hawaii law, you are entitled to request an external review in the following if your insurer still denies you coverage after the conclusion of an internal appeal.[7]

You can also request an expedited external review if waiting 60 days would seriously jeopardize your life, health, or ability to regain functioning. You can request an expedited external review while you request the expedited internal appeal.[8]

You should submit your request for external review to the Hawaii Division of Insurance (“Division”) within 130 days from of your insurer’s last determination letter.[9] To request an external review, you should take the following steps:

  • Request documents from your insurer. Ask your insurer for a copy of the final determination letter from the internal appeal, a signed consent to release your medical records, and a conflict of interest disclosure form.[10]
  • Prepare a cover letter. Prepare a cover letter to the Division. The cover letter should contain the following information:
  • Whether you are requesting a standard or an expedited external review;
  • An explanation, in detail, why you believe you are entitled to the coverage or reimbursement that you are seeking;[11] and
  • An explanation of why you believe the denial of coverage in your case was wrong.[12]
  • Send a filing fee. You should send a check for $15, made payable to the “Department of Commerce and Consumer Affairs” along with your applicable. The filing fee is refundable if the Division determines that your insurer should have covered your claim.[13]
  • Submit your request. Send your request for an external review and supporting documents to the Division at the following address:
  • Division of Insurance
    P.O. Box 3614
    Honolulu, HI 96811

The external review process should take no more than 45 days after receiving your request.[14] If you requested an expedited external review, the process should take no more than 72 hours after receiving your request.[15]

If you are a Hawaii resident and your insurer denies your coverage after the external review process, you should speak with an investigator within the Division to determine if an informal resolution is possible. You can speak with an investigator by calling (808) 586-2790 between the hours of 7:45 a.m. and 4:30 p.m., Monday through Friday.[16]

If an informal resolution is not possible, you can file a complaint with the Insurance Division.

Complaint information. You can find a copy of the complaint form here. Your complaint should include the following information:

  • The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
  • What you consider to be a fair resolution.[17]

Supporting documents. You should submit the following documents as supporting information:

  • 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. [18]

How to submit. You can submit the complaint and supporting documents by fax to (808) 587-5379 or by mail to:

Hawaii Insurance Division
Health Insurance Branch
P.O. Box 3614
Honolulu, HI 96811[19]

The Division will investigate your claim and attempt to resolve it with your health insurer. The Division can force your insurer to comply with your insurance policy, issue a citation, or fine the insurer for failure to comply. The Division can also force the insurer to reimburse you for your time and any fees you incurred in filing the complaint.

You can contact the Hawaii Division of Insurance at (808) 586-2790. The Division is open from 7:45 a.m. to 4:30 p.m. Monday through Friday.

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 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 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.

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.[2]

During 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 Vermont law, you are entitled to request an external review for

  • Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
  • Any denial that involves a determination that a treatment is experimental or investigational
  • Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage.[4]

You can also skip the internal appeal process altogether and request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function.[5]

You should submit your request for an external review to the Vermont Department of Financial Regulation (“Department”).[6] You can find a copy of the external review request form here.

Information. You should include the following information in your request:

  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • The name of the person at the insurance company involved with your appeal;
  • Subscriber or member number and insurance claim or reference number;
  • Brief description of decision in dispute; and
  • The name, type of provider, address, and telephone number of your health care provider.

Filing fee. You must submit a $25 filing fee by check or money order with your request. The fee can be waived for financial hardship.[7] If you believe you have a financial hardship, you should complete the “Request to Reduce or Waive Filing Fee” section of the external review request form (bottom of page 2 of the form).[8] If you complete that section, do not submit the filing fee.[9]

Supporting documents. You should include the following documents with your request:

  • A copy of the denial letter from your health insurer; and
  • Any new information and documentation that you had not included with your prior request for an internal appeal.

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

David Martini, Esq.
Director External Appeals Program
Vermont Department of Financial Regulation
89 Main Street
Montpelier, VT 05602[10]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Department at (800) 964-1784 or (802) 828-3302. If it is an emergency, you can contact the External Appeals answering service at (888) 236-5966 after hours.[11]

You must file your written request for an external review within 120 days or four months, whichever is longer, from the date that your insurer sent you the final decision.[12] You should contact Consumer Services at (800) 964-1784 or (802) 828-3302 as soon as possible after receiving an adverse decision from an internal appeal.[13]

The external review process should take no more than 30 days from the date the external review organization receives all the information related to your claim.[14] If you request an expedited external review, the process should take no longer than four business days after your request is received.[15

If you are a Vermont resident and you believe your insurer did something illegal or unethical, 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 insurance company;
  • Policy number, claim number, date of loss, date of service, and type of service;
  • The type of coverage;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[16]

Supporting documents. You should submit the following documents as supporting information:

  • 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.[17]

How to submit. The complaint may be submitted online here, faxed to (802) 828-1446, or mailed to the following address:

Consumer Services
Department of Financial Regulation
89 Main Street
Montpelier, VT 05620-3101[18]

The Department will write to your health insurer and request a response. Your insurer must respond immediately upon receipt of the complaint. The Department will also review your complaint and take any necessary actions. The length of the process will depend on how complicated your case is.[19] The Department can require the insurer to reverse its decision depending on the circumstances of your case.

You can contact the Department at (800) 964-1784. The Department is open from 7:45 a.m. to 4:30 p.m. Monday through Friday.

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. The appeal process differs based on whether you have an employer-sponsored group plan or any other type of plan.

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 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. You can request an expedited internal appeal if your case involves urgent or emergency care, an admission, availability of care, continuation of a stay, and situations in which you have received emergency services and have not yet been discharged from the facility.[2] If you believe you qualify or an expedited internal appeal, you should contact your insurer and ask for instruction on how to request one.
  • 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.

If you have an employer-sponsored group plan, you will need to complete two stages of internal appeals.[3] During the first stage, you or your provider should call your health insurer’s medical director or the physician responsible for denying your claim.[4] You may also have to complete all the steps listed above in section I. Your insurer can provide you with clarification.

During the stage-two appeal, you or your provider can appeal the denial to a panel of physicians or other health care professionals selected by your health insurer.[5]  The providers on the panel must not have been involved in the original denial of your claim and must have access to practitioners who are trained in or who specialize in the condition for which you are seeking treatment.[6] You should contact your insurer for instructions on how to request a stage-two appeal.

The first stage of an internal appeal should take no longer than 10 days to complete, while the second stage should be completed in no more than 20 business days.[7]

For expedited internal appeals, the first stage should be completed within 72 hours, and the second stage should also be completed within 72 hours.[8]

During an external review, an independent third party reviews your insurer’s decision.[9] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New Jersey law, you are entitled to request an external review if:

  • Your insurer denies your internal appeal because it determined that the requested treatment or services were medically unnecessary, experimental, or investigational;
  • Your insurer has not complied with the deadlines for deciding your internal appeal;
  • Your insurer has waived the internal appeals process; or
  • Your situation is urgent and you requested an expedited internal appeal and an expedited external review at the same time.[10]

You can request an expedited external review if:

  • You seek urgent or emergency care, an admission, availability of care, or continuation of a stay;
  • You have received emergency services and have not yet been discharged; or
  • Waiting 10 to 20 days could seriously jeopardize your life, health, or ability to regain function.[11]

You should submit your request for an external review to the New Jersey Department of Banking and Insurance (“Department”) within four months from when your insurer sent you the most recent decision.[12]

Information. You can find a copy of the external review request form here. You should include the following information in your request:

  • The name, address, telephone number, email address, and date of birth of the insured individual;
  • The name of the insurance company;
  • The identification number and policy number;
  • The name, address, telephone number, and email address of the person filing the request and his or her relationship to the patient;
  • A description of the reason for the appeal; and
  • If you are requesting an expedited external review, a statement that you are requesting expedited review and the reasons why you believe expedited treatment is needed.[13]

Supporting documents. You should include copies of the following supporting documents with your request:

  • A signed medical records release form;
  • All information submitted to the health insurer;
  • Any additional or new information you would like the external review organization to consider;
  • A copy of the initial denial letter from your health insurer; and
  • Copies of the insurer’s decisions on the internal appeals.[14]

Do not send copies of your medical records with the request. The Department will give you instructions on how to submit copies of your medical records after the external review organization accepts your request.

Submitting a standard external review. You can email your request to [email protected], or mail it to:

NJ Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
P.O. Box 329
Trenton, NJ 08625-0329[15]

(If using courier service: 20 West State St., 9th Floor)

Submitting an expedited review. For expedited requests, you can fax the request and supporting documents to (609) 633-0807.

Filing Fee. There is a $25 processing fee for applications accepted by the external review organization. The fee may be waived if you can show financial hardship.

The external review process should take no more than 45 days after the external review organization has received your request. If you requested an expedited external review, the process should take no more than 48 hours.[16]

If you are a New Jersey resident and your insurer still denies your claim 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 the insurance company;
  • The policy number, claim number, and date of loss/claim;
  • The nature of the complaint;
  • The details of the complaint; and
  • The action requested.[17]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters 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.[18]

How to submit. The complaint may be submitted online here, faxed to (609) 454-8468, or mailed to the following address:

New Jersey Department of Banking and Insurance
Consumer Inquiry and Response Center
P.O. Box 471
Trenton, NJ 08625-0471[19]

Your complaint will be assigned to an investigator. The investigator will review the complaint and contact your health insurer for a response. The insurer has 14 days to respond. Once the review is complete, the investigator will notify you of any action taken.[20] The Department can force the insurer to cover the claim, or issue a citation or fine. If a death has occurred because of action or inaction by the health insurer, the Department can bring criminal charges against the insurance company. Complaints are usually resolved within 60 days.

You can contact the New Jersey Department of Banking and Insurance at (609) 292-7272 or through the Consumer Hotline at (800) 446-7467. The Department is open from 9:00 a.m. to 4:00 p.m., Monday through Friday.

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 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 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.

The internal appeals process should take a maximum of 45 days from the date that the insurer received your request for appeal.[2]

During 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. Pursuant to Delaware’s Independent Healthcare Appeals Program, you are entitled to request an external review if your insurer denies you coverage or preauthorization request after you requested an internal appeal.[4]

You can skip the internal appeals process and request an expedited external review if you have a condition that poses an imminent, emergent, or serious threat or have an emergency medical condition.[5]

You should submit a request for an external review to your insurer by completing an appeals form that your insurer provides to you within four months from the date on the first appeal denial letter.[6] Be sure to inform your insurer on the appeals form whether you are seeking a standard or an expedited external review.

Your insurer will then forward the request to the Delaware Department of Insurance with an email outlining the plan type and the reason for the denial of coverage.[7] The Department will then refer the request to an independent outside review organization. The insurer must submit complete plan information, complete claim information, and all medical records and other documents used to make its decision to the review organization.[8] The reviewer will select three independent medical providers to review the appeal and provide a final decision.[9]

The external review organization should respond to you within 45 days of receiving the application. If you request an expedited external review, the process should take no more than three business days after your request is received.[10]

If you are a Delaware resident and your insurer denies your coverage after the external review process, you can file a complaint with the Delaware Department of Insurance (“Department”).

Complaint information. Your complaint should include the following information:

  • The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
  • What you consider to be a fair resolution.

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 appeals and complaints;
  • Supporting documentation from your health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[11]

How to submit. You can complete and submit a complaint online here. If you submit an online application, you should electronically attach supporting documents to the online complaint. Alternatively, the complaint and supporting documents can be faxed to (302) 739-6278 or mailed to:

Delaware Department of Insurance
Consumer Services Division
841 Silver Lake Blvd.
Dover, DE 19904[12]

The Department of Insurance will assign someone to investigate your complaint.[13] The That representative may question witnesses, request additional documents from other parties, and hold a hearing.[14]

You can contact the Delaware Department of Insurance at (302) 674-7310 or (800) 282-8611.  The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.

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 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 appeal, if applicable. You can request an expedited internal appeal if you need emergency health care services or if your life is in jeopardy.[2] Your health insurer is required to notify you of the process for requesting an expedited internal appeal with the initial denial letter.[3] You should follow those instructions closely.
  •  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.
  • File for a second level internal appeal. If the insurer denies your claim during the initial (first level) internal appeal, you may request a second level internal appeal.[4] During the second level internal appeal, you can inspect your insurer’s file on you and submit any additional documents.[5] Your health insurer should have provided you with instructions on how to request a second level internal appeal when it denied your first level appeal.[6] You should follow those instructions closely.

The first level and second level internal appeals process should take a maximum of 21 business days for each level of appeal.[7] An expedited internal appeal should be completed within two business days after the appeal is filed and the insurer receives all necessary information.[8]

During an external review, an independent third party reviews your insurer’s decision.[9] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Rhode Island law entitles you to request an external review if your insurer denies your coverage after an internal appeal.

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function. If you are requesting an external review, you should contact your insurer to determine if you can skip the internal appeal process altogether.

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.[10] You must also send your insurer a check for half of any fee required.[11] The notice of denial from the second level of internal review will include information regarding the fee requirements for an external review.[12] The fee will be refunded to you if the external review agency decides in your favor.[13] You should also include any additional or new information that you did not include with your request for an internal appeal.

Your health insurer must forward your request and supporting documentation to the external review agency within five days of receiving your request for external review.[14]

The external review agency should send you its decision within ten business days from receiving the necessary documentation.[15] If you request an expedited external review, the process takes no longer than two business days.[16]

If you are a Rhode Island resident, you can file a complaint with the Rhode Island Department of Business Regulation, Insurance Division, if your claim is denied after the external review process and you believe that your health insurer has done something illegal or unethical.

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person making the complaint (“Complainant”);
  • The name of the insured individual;
  • The names of other parties involved in the dispute;
  • The name of the insurance company, insurance agency, and agent, adjuster, or appraiser;
  • The policy number, certificate number, claim number, and date of loss;
  • The type of insurance and reason for complaint; and
  • The details of your complaint.[17]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of the determination letters 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.[18]

How to submit. The complaint may be submitted online here, faxed to (401) 462-9602, emailed to [email protected], or mailed to the following address:

State of Rhode Island and Providence Plantations
Department of Business Regulation
Insurance Division
1511 Pontiac Avenue, Bldg. 69-2
Cranston, RI 02902[19]

Note that the Insurance Division does not have the authority to require an insurer to pay a claim.[20] If your case involves failure of your health insurer to pay your claim, you should contact the Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline (“RI REACH”) at (855) 747-3224 to file a complaint. A representative of RI Reach will be able to assist you through the process.

Once the Insurance Division receives your complaint, it will determine whether it can handle your claim.[21] If it decides to handle your claim, it will send you an acknowledgement letter. It will also send a copy of your complaint to your health insurer for a response.[22] The insurer typically responds within three days. The Insurance Division will review the insurer’s response and conduct an investigation. Once the Insurance Division has concluded its investigation, it will send you a letter with its findings.[23]

You can contact the Rhode Island Insurance Division at (401) 462-9520. The Division is open from 8:30 a.m. to 4:00 p.m., Monday through Friday.

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 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 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 review from your insurer if the internal appeal is from a decision regarding urgent or emergency medical conditions.[2] You have the right to continued coverage at the level of benefits provided prior to the reduction, termination, or limitation pending the outcome of an expedited appeal.[3] Your insurer should have provided you with its requirements for requesting an expedited internal appeal process with your initial determination letter.[4] Be sure to follow those instructions.
  • 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.

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 requested service or treatment but are waiting for reimbursement.[5] The process should take a maximum of 24 hours if the internal appeal involves an urgent or emergency medical condition.[6]

During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

Under District of Columbia law, you are entitled to request an external in the following circumstances:

  • Your insurer denies your coverage after an internal appeal within the allotted timeframe;
  • The insurer waives the requirement that the internal appeals process be completed before proceeding to external review; or
  • The insurer does not comply with the deadlines and requirements of the internal appeals process.[8]

You can request an expedited external review if you have an urgent or emergency medical condition. If you believe you qualify for an expedited external review, you can apply for that at the same time that you apple for an expedited internal appeal.

You must file your request for an external review with the District of Columbia Office of Health Care Ombudsman and Bill of Rights within four months of the date on your insurer’s most recent decision.

Information.

You can find a copy of the external review request form here.[9] You should include the following information:

  • The name of the person requesting review;
  • The name and address of the insurance company;
  • A description of the review requested;
  • The patient’s name, date of birth, gender, address, telephone number, and email address;
  • The patient’s diagnosis and procedures performed;
  • The name, address, and telephone number of the referring physician;
  • The name, address, and telephone number of the treating facility;
  • Member identification number
  • Date of final decision; and
  • Basis for the appeal.[10]

Supporting documents.

You should also include the following supporting documents with your application:

  • A copy of all determination letters from your health insurer;
  • A signed medical records release form here; and
  • Any medical records, health care provider statements, and other information for the external review agency to consider.[11]

How to submit an external review request.

You can submit your request and supporting documents by fax to (202) 478-1397 or by mail to the following address:[12]

Government of the District of Columbia
Office of Health Care Ombudsman and Bill of Rights
One Judiciary Square
441 4th Street, NW, Suite 900S
Washington, DC 20001

Questions.

If you have questions regarding the process, you can contact the Office of Health Care Ombudsman and Bill of Rights at (977) 685-6391.

The external review process should take a maximum of 45 calendar days to complete.[13] An expedited external review should be completed within 72 hours.[14]

If you are a resident of the District of Columbia and your claim is denied after the external review process, you can file a complaint with the Department of Insurance, Securities and Banking (“Department”).

Complaint information.

You can find the complaint form here. 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, if different than the Complainant;
  • The name, address, and telephone number of insurance company;
  • The name and title of any person you’ve spoken with about your claim at the insurance company as well as the date and place;
  • Policy number, group name or number, claim number, date of coverage, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[15]

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.[16]

How to submit.

You can submit your complaint and the supporting documents online here, by faxing them to (202) 354-1085, by emailing them to [email protected], or my mail or hand delivered to the following address:

District of Columbia Department of Insurance, Securities, and Banking
Attn: Consumer Services Division
810 First Street, NE, Suite 701
Washington, DC 20002[17]

The Department will look into your complaint to see if any District laws or procedures have been violated.[18] A representative will contact your insurance company to obtain information and an explanation from the insurer.[19] Most complaints are investigated and resolved within 45 days.[20]

If you have questions regarding filing a complaint, you can contact the Department at 202-727-8000 or you can email them at [email protected]. The Department is open from 8:15 a.m. to 4:45 p.m., Monday through Friday.

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 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.[2]
  • 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.

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.[3]

You can skip the internal appeals process and request an expedited external review in urgent situations or if the denial of services relates to a mental health or substance use disorder.[4] Your situation is urgent if waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function.

If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[5] During an external review, an independent third party reviews your insurer’s decision.[6]

In Connecticut, you may only obtain an external review if your plan was supposed to cover your treatment, but your insurer denied your claim for one of the following reasons:

  • The requested treatment was not medically necessary;
  • The treatment was experimental or investigational;
  • You are not eligible for the treatment or medication; or
  • Your insurer rescinded your policy.[7]

If you meet these criteria, you can obtain a standard external review or an expedited external review by taking the following steps:

Prepare application. Prepare the following materials:

  • The external review request form (click here);
  • A copy of your medical insurance identification card;
  • A copy of the final denial letter from your insurance company;
  • A letter of support, treatment notes, and test results from your health care provider;
  • Your personal description of the issue;
  • Any current medical literature or studies showing the effectiveness of the treatment you are requesting, if such treatment has been denied as experimental/investigational;
  • Any medical documents not previously submitted to your insurance company; and
  • The $25 filing fee (payable by check or money order) or a request for a waiver of the filing fee, which will be included in the external review packet.[8]

Ask for certification for expedited external reviews. If you are requesting an expedited external review, in addition to the materials above, you should also ask your health care provider to complete the Physician Certification Form (click here), and you should submit that form with your request.[9] If the services relate to a mental health disorder or substance use disorder, an expedited external review will automatically be granted and the Physician Certification Form is not required to be submitted.[10]

Submit your request. Mail your application materials to:

Connecticut Insurance Department
Attn: External Review
P.O. Box 816
Hartford, CT 06142-0816[11]

You should mail your request for an expedited review and supplemental documents overnight to:

Connecticut Insurance Department
Attn: External Review
153 Market Street, 7th Floor
Hartford, CT 06103[12]

You must request an external review within 120 days of receiving the last decision letter from your insurer.[13] Be sure to make a copy of all documentation for your own personal records.

The length of time for an external review process varies based on the services or treatment you requested and whether you request an expedited external review.

External Review

  • Standard treatment: No more than 45 days.
  • Experimental or investigational treatment: No more than 20 days.[14]

Expedited External Review

  • Standard treatment: No more than 72 hours;
  • Experimental or investigational treatment: No more than four days;
  • Specific behavioral health services (automatically expedited): No more than 24 hours.[15]

If you are a Connecticut resident and your insurer denies your coverage after the external review process, you can file a complaint with the Connecticut Department of Insurance (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The names of any other parties involved (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.[16]

You can submit the following supporting documentation with your complaint:

  • Medical bills;
  • Contracts; and
  • Correspondence between you and your insurer.[17]

You can submit your complaint online here. If you submit an online complaint, you should scan the supporting documents and attach them to your complaint.[18]Alternatively, you can print a copy of the complaint found here and mail it along with the supporting documents to:

Connecticut Insurance Department
Attn: Consumer Affairs Division
P.O. Box 816
Hartford, CT 06142-0816[19]

The Department will assign an analyst to review your complaint.[20] You will receive acknowledgment of receipt of the complaint and a copy will be sent to your health insurer for a response.[21] Once the response is received, the analyst will determine how to resolve the complaint.[22] Upon investigation, the Department will either require the insurance company to cover the claim or deny the claim.

You can contact the Connecticut Consumer Affairs Division helpline at (860) 297-3900 or (800) 203-3447. The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.

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 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 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.

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.[2]

During 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 New Hampshire law, you are entitled to request an external review if your insurer denies your appeal, and the denial was based on the insurer’s belief that the recommended treatment or service:

  • Is not medically necessary,
  • Is not appropriate for your condition, or
  • Does not meet the insurer’s requirements for health care setting or level of care or effectiveness.[4]

You can request an expedited external review if your medical situation is urgent and waiting will jeopardize your health, life, or ability to function.

You should submit your request for external review to the New Hampshire Insurance Department (“Department”) within 180 days from when your insurer sent you the most recent decision.[5]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • The name, address, email address, and telephone number of the applicant;
  • The patient’s name and date of birth (if different from the applicant);
  • The name and relationship to patient of the insured;
  • The name, address, and telephone number of the insurance company;
  • The name of the claim representative handling your appeal;
  • Member identification number and claim or reference number;
  • The name and telephone number of the employer;
  • The name, address, and telephone number of your primary care provider;
  • The name, address, telephone number, and specialty of your treating health care provider; and
  • Description of the complaint; and
  • The health care provider certification form in the external review application (this form is only required for expedited external review requests.)[6]

Supporting documents. You should also include the following supporting documents with your request:

  • A signed medical records release form (included in the external review form packet);
  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of medical records, statements from your health care provider, or other information you’d like the external review organization to consider;
  • A copy of your insurance policy; and
  • Any new information or documentation not included with your request for an internal appeal.[7]

Submitting a standard external review. If you are requesting a standard external review, you should mail the completed form and supporting documents to the following address:

New Hampshire Insurance Department
Attn. External Review Unit
21 South Fruit Street, Suite 14
Concord, NH 03301[8]

Submitting an expedited review. If you are requesting an expedited external review, you can fax your request to (603) 271-1406 or send it by overnight mail to the address above.[9]

The external review process should take no longer than 60 days.[10] If you requested an expedited external review, the process should take no longer than 72 hours.[11]

If you are a New Hampshire resident and you believe that your insurer did something illegal or unethical, 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 or policy number, date of issue, claim number, and date of loss;
  • The reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[12]

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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[13]

How to submit. The complaint and supporting documents may be submitted online here, faxed to (603) 271-1406, or mailed to the following address:

New Hampshire Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301-2430[14]

Once the Department receives your complaint, a Consumer Service Officer will determine if the Department has the authority to handle your claim. If the Department does have the authority, your complaint will be forwarded to your health insurer for a response. The insurer should respond to the Department within ten business days.[15] The total investigation time varies, but most cases are resolved within 45 days. The Department can force the insurer to cover the claim, issue a citation, or fine the insurer. If the Department determines that your health insurer knowingly violated a law or regulation, it can lose its license to offer insurance in New Hampshire.

You can contact the New Hampshire Department of Insurance at (800) 852-3416. The Department is open from 9:30 a.m. to 4:30 p.m., Monday through Friday.

If your insurer denies your claim, you have the right to file a grievance with your health insurer.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 file a grievance.

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.[2]

Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing a 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 file a grievance and draft a strong grievance letter.

Submit the appeal 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.

Ask for an expedited review, if applicable. You can request an expedited grievance review from your insurer if one of the following circumstances applies to you:

  • You are in the hospital;
  • Denial of services would create a risk of immediate serious harm;
  • You have a terminal illness; or
  • You are in urgent need of services.[3]

Your insurer should have provided you with its requirements for requesting an expedited internal grievance process with your initial determination letter.[4] Be sure to follow those instructions.

  • 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.
  • Complete additional levels. Your health insurer may require two or more levels of internal review in the grievance process.[5] You should check your insurance policy, benefits booklet, and any information you received with your determination letter from your health insurer to ensure that you follow the process your health insurer requires.[6]

The grievance process should take a maximum of 30 business days, regardless of how many internal levels of review your health insurer requires.[7]

An expedited grievance review should take no longer than 48 hours once your physician certifies that there is a substantial risk of immediate harm if you are not provided the service or treatment or within five days if you are terminally ill.[8] If you are in the hospital, your health insurer must provide you with a decision about inpatient care prior to your discharge from the hospital.[9]

Under Massachusetts law, if your insurer fails to provide a decision within the allotted time periods, the insurer must cover the service or treatment you requested.[10]

During an external review, an independent third party reviews your insurer’s decision.[11] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

Under Massachusetts law, you are entitled to request an external review in the following circumstances:

  • Your insurer denies your coverage after an internal grievance review within the allotted timeframe;
  • There is a serious and immediate threat to your health (in this case, you should apply for an expedited external appeal).[12]

You can file a request for an expedited external review at the same time that you request an expedited internal grievance review.[13]

You must file your request for an external review with the Massachusetts Office of Patient Protection (“Office”) within four months of the date on your insurer’s most recent decision.

Information. You can find a copy of the external review request form here.[14] You should include the following information:

  • Patient’s name, address, telephone number, and date of birth;
  • Policyholder’s name;
  • Patient’s insurance identification number;
  • Name of health insurance company;
  • Name of the person at the insurance company involved with the appeal;
  • Description of the problem;
  • Name, address, and telephone number of the health care provider who ordered the service which was denied; and
  • Information regarding your health history, if you want that information to be considered by the external review agency.[15]

Supporting documents. You should also include the following supporting documents with your application:

  • A copy of all determination letters from your health insurer;
  • A signed medical records release form (included with request packet);
  • A copy of your insurance card; and
  • Any medical records, health care provider statements, and other information for the external review agency to consider.

If you are requesting an expedited external review, you should also include the following documents with your application:

  • The “Request for Expedited Review” section on page 9 of the external review request packet;[16] and
  • The “Certification for Expedited External Review” form included on pages 10 – 11 of the external review request packet.[17]

Filing fee. You must include a $25 filing fee with your application. The fee is payable by check or money order.[18] If the external review is resolved in your favor, the Office will refund your payment. If the fee would create an extreme financial hardship for you, you can request a waiver of the fee by completing a fee waiver form. The form is on page 8 of the external review request form, which can be found here. The form contains a chart, which explains what qualifies as “extreme financial hardship.”

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request and supporting documents by fax to (617) 624-5046 or by mail to the following address:[19]

Office of Patient Protection
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109

How to submit an expedited external review request. If you are requesting an expedited external review, you should fax your request and supporting documents to the Massachusetts Office of Patient Protection at (617) 624-5046.[20]

The external review process should take no more than 45 days from the date the external review agency receives the request. If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[21]

If you are a Massachusetts resident and your insurer still denies your claim after the external review process, you can file a complaint with the Massachusetts Division of Insurance (“Division”).

Complaint information. You can find the complaint form here. 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 insurance company;
  • The state where the insurance plan was purchased;
  • The group number, certificate number, policy/ID number, claim number, and date of loss; and
  • The details of the complaint.

You should submit the following documents as supporting information:

  • 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.[22]

You can submit your complaint and the supporting documents by faxing them to (617) 753-6830 or mailing them to the following address:

Office of Consumer Affairs and Business Regulation
Division of Insurance
1000 Washington Street, Suite 810
Boston, MA 02118-6200[23]

The Division will provide a copy of your complaint to your health insurer and attempt to resolve the issue. The Division may negotiate a settlement or hold an administrative hearing.[24] If the Division determines that your health insurer has violated a law or regulation, the Division can make your insurer pay a penalty.[25]

You can contact the Massachusetts Division of Insurance at (617) 521-7794 or (877) 563-4467. The Division is open from 8:45 a.m. to 5:00 p.m., Monday through Friday.

If your insurer denies your claim, you have the right to submit an internal grievance with your health insurer.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 to understand why your insurer denied your claim and how to file a grievance regarding the denial.
  • Collect information. In addition to the determination letter, collect all the documents 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 a 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 file a grievance and draft a strong appeal letter.
  • Seek assistance from the state. If you would like additional help with the grievance process, you can contact the Maryland Attorney General’s Health Care Education and Advocacy Unit (“Unit”). The Unit will assist you, free-of-charge, with filing your appeal. You can reach the Unit at (877) 261-8807.[2]
  • Submit the appeal 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. This should be done within six months from the date the claim was denied. 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.
  • Ask for an expedited procedure, if applicable. You can request an expedited internal grievance procedure in emergency situations.[3] Your situation is an emergency situation if your life or health would be in serious jeopardy or you would be a danger to yourself or others if you do not receive the requested treatment immediately.[4]
  • 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.

The internal grievance process should take a maximum of 30 business days if you have not yet received the requested treatment or service. It should take a maximum of 45 business days if you have received the requested service but payment has been denied. If you choose to do so, you can give your insurer an extension of up to an additional 30 business days.[5]

If you request an expedited procedure, the process should take no more than 24 hours from the time you filed your request.[6]

During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

 You are entitled to an external review in the following circumstances:

  • Your insurer denies your coverage after an internal appeal because your insurer determined your claim was not medically necessary, medically inappropriate, or is considered cosmetic, experimental or investigational; or
  • Your medical situation is urgent and waiting would jeopardize your life or ability to function.

Please note that if your situation is urgent, you do not need to wait for a decision from your insurer on the internal grievance. You can request an expedited external review while you request an expedited internal grievance from your insurer.

You should submit your request for external review to the Maryland Insurance Administration (“Administration”) within 120 days from the date that the claim was denied.[8]

How to submit a standard external review request. You should mail a written request to the Administration. You should include any new information and documentation that you did not previously include with your internal grievance request. For information on properly submitting a request, you should contact:[9]

Maryland Insurance Administration
Attn: Appeals and Grievance Unit
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
(410) 468-2000 or 1-800-492-6116

How to submit an expedited external review request. If you are requesting a standard external review for urgent care, you should contact your health insurer at the phone number on the back of your insurance card. You can also contact the Administration by phone at (410) 468-2000 or (800) 492-6116, by fax at (410) 468-2270, or at the following address to request assistance:

Maryland Insurance Administration
Attn: Appeals and Grievance Unit
200 St. Paul Place, Suite 2700
Baltimore, MD 21202[10]

The external review process should take no more than 60 days. If you requested an expedited external review, the process should take no longer than four business days after your request is received.[11]

If your insurer denied your claim because your plan does not cover the treatment or service, and you do not qualify for an external review, you still have another option. You can contact the Employee Benefits Division (“Division”) to request an additional review of your health insurer’s decision.[12] The Employee Benefits Division can be reached by phone at (410) 767-4775 or (800) 307-8283, by fax at (410) 333-7104, or by mail at the following address:

Employee Benefits Division
Attn: Adverse Determinations
301 West Preston Street, Room 510
Baltimore, MD 21201[13]

The Administration protects consumers from illegal insurance practices.[14] If you are a Maryland resident and you believe your insurer did something illegal, you can file a complaint with the Administration.

Information. You can find a copy of the complaint form here. Your complaint should include the following information:

  • The name, address, email address, telephone number, and relationship to insured/patient of the person filing the complaint (“Complainant”);
  • The name, address, email address, and telephone number of the insured/patient, if different than Complainant;
  • The name of the insurance company;
  • If a group plan, the name of the group policyholder;
  • Policy or member identification number, claim number, date of claim;
  • If an employer-provided policy, the name and address of the employer;
  • The name, address, and telephone number of the treating health care provider;
  • A brief explanation of the problem; and
  • What you consider a fair resolution.[15]

Supporting documents. You should include the following supporting documents with your complaint:

  • A signed medical record release form (included with the complaint packet);
  • 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.[16]

 How to submit. You should submit your complaint and the supporting documents by fax to (410) 468-2260 or by mail to:[17]

Maryland Insurance Administration
Attn.: Consumer Complaint Investigation
200 St. Paul Place, Suite 2700
Baltimore, MD 21202

After the Administration receives your complaint, a representative will investigate. The process can take a few months to complete.[18] At the end of the representative’s investigation, the Commissioner of Insurance may require the health insurer to stop inappropriate conduct, fulfill its contractual obligations, or provide the service or treatment that was denied. The Commissioner can also require the insurer to pay a penalty or fine.[19]

If you file a complaint with the Administration, you can reach the agency at (410) 468-2000 or (800) 492-6116. The Administration is open from 8:00 a.m. to 5:00 p.m., Monday through Friday. You can also reach the agency after hours if you have an emergency medical situation.

You can also file a complaint with the Maryland Attorney General’s Office, either at the same time you file a complaint with the Maryland Insurance Administration or in lieu of filing a complaint with the Administration.

Complaint information. You can find a copy of the complaint form here. Your complaint should include the following information:

  • The name, address, email address, telephone number, and date of birth of the patient;
  • The name, address, email address, telephone number, and relationship to patient of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • The group name or number, membership number, and date appeal was filed with your health insurer;
  • The name, business address, telephone number, and email address of your health care provider;
  • The name, address, telephone number, and email address of any other health care providers involved in your case;
  • Whether the patient has received service or care;
  • A description of the complaint; and
  • What you consider to be a fair resolution of the complaint.[20]

Supporting documents. You should submit the following supporting documents with your complaint:

  • Signed authorization to release medical information (in the complaint packet);
  • A copy of the confirmation page you received after submitting your complaint online (if you submitted your complaint online);
  • A copy of any bills, records, or correspondence related to your complaint;
  • A copy of any correspondence from the health insurer related to the 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.[21]

How to submit. The complaint may be submitted online here, faxed to (410) 576-6571, or mailed to the following address:

Office of the Attorney General
Consumer Protection Division
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202[22]

Once the Attorney General’s Office receives your complaint, the representative will review the complaint and ensure that it is the best agency to handle it.[23] If the Attorney General’s Office determines that your complaint would be better handled by another agency, it will forward your complaint to that agency.[24] Otherwise, the Attorney General’s Health Education and Advocacy Unit will assign your complaint to a mediator who will then mediate the issues between you and your health insurer.[25] During the mediation process, the Attorney General’s Office cannot compel your health insurer to take any action.[26] If you are unable to come to an agreement during mediation, you can agree to submit to binding arbitration or file a complaint in state court.[27]

You can contact the Maryland Attorney General’s Office at (410) 528-1840 or (877) 261-8807. The Office is open from 9:00 a.m. to 4:30 p.m. Monday through Friday.