Alaska

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • 1. Appeal the decision;
  • 2. Request an external review; and
  • 3. File a complaint.

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.