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]