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 independent medical review; and
  • 3. File a complaint.

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.