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  • Your insurer rescinded your policy.[7]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.