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 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 expedited 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.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] You can request an external appeal in the following circumstances:

  • You requested an internal appeal from your insurer, but your insurer did not provide you with a prompt hearing or a decision within 30 days (if you have not yet received the requested service or treatment) or 60 days (if you have received the service or treatment but are waiting for reimbursement);[7]
  • Your insurer denies your internal appeal;
  • Your situation is urgent (request an expedited external review);[8]
  • Your health insurer denied your claim because it deemed your requested treatment “experimental” and you meet all of the following criteria:
    1. You have a terminal condition with a substantial probability of death within two years or your ability to regain or maintain function would be impaired;
    2. You have already tried standard treatments, your health care provider certifies that the standard treatment is not medically indicated for your condition, or there is no standard treatment;
    3. Your health care provider recommends and certifies in writing that the proposed treatment is more beneficial to you than the standard treatment;
    4. Your health care provider has certified in writing that scientific studies, using accepted protocols and published in peer reviewed literature, demonstrate that the proposed treatment is likely to be beneficial to you than the standard treatment; and
    5. Your insurance policy says that the treatment should be covered, and the only reason it was not covered was because your insurer determined that it was experiment.[9]

You should submit a written request for a standard or an expedited external review to the Georgia Department of Insurance.[10] Your insurer should have provided you with instructions on how to submit the request and what information, documentation, and procedures are required for external review of your case.[11] If you cannot find the instructions, contact your insurer.

The external review process should take no more than 30 days.[12] If you request an expedited external review, the process should take no longer than 72 hours after your request is received by the independent reviewer.[13]

If you are a Georgia resident and your insurer denies your coverage after the external review process, you can file a complaint with the Georgia Department of Insurance (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint.

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 and supporting documents may be submitted online here. Alternatively, the complaint and supporting documents can be faxed to (404) 657-8542 or mailed to:[15]

Georgia Department of Insurance
2 Martin Luther King Jr. Drive, Suite 716, West Tower
Atlanta, Georgia 30334

The Department will assign an investigator to your case. The investigator will then work with your health insurer and you to resolve the issue.[16] If the investigator determines that the insurer violated a law or policy, it will take corrective action.

You can contact the Georgia Department of Insurance at (404) 656-2070 (in the Atlanta metro area) or (800) 656-2298 (outside the Atlanta metro area). The Department phone lines are open from 8:00 a.m. to 7:00 p.m. Monday through Friday.