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.