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]

A. Expedited Internal Appeals for Increased Health Risks

You can request an expedited internal appeal if:

  • You are currently receiving health care services and you could experience a significantly increased health risk if your insurer denied those services; or
  • Your insurer denied a treatment referral, service, procedure, or other health care service and the denial significantly increases the risk to your health.[4]

To obtain an expedited internal appeal, contact your insurer and request an expedited internal appeal either orally or in writing, depending on your health insurer’s policy.[5] Your determination letter should provide specific instruction about how to request the expedited internal appeal.

Once you request the appeal, your health insurer should notify you within 24 hours to either (1) ask for any additional information it needs to evaluate the appeal; or (2) to provide you with a decision. If the insurer asked for additional information, it should provide you with a decision within 24 hours of receiving the additional information.[6]

B. Expedited External Reviews for Urgent Situations

In urgent situations, you can skip the internal and expedited internal appeals processes and request an expedited external review instead. Your situation is urgent in the following circumstances:

  • You have a medical condition and waiting 48 hours for treatment would jeopardize your life, health, or your ability to regain function; or
  • Your insurer deems your requested treatment “experimental” or “investigational,” and your health care provider certifies that the treatment would be significantly less effective if it is delayed.[7]

During an external review, an independent third party reviews your insurer’s decision.[8] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal and did not receive a response within 30 days (if you did not receive the requested treatment or service) or 60 days (if the insurer denied payment for a treatment or service you did receive);[9]
  • You requested an expedited internal appeal and did not receive a response within 48 hours;
  • You received a denial letter after requesting an internal appeal or expedited internal appeal; or
  • Your insurer still denies you coverage after you requested an internal appeal.

To obtain an external review or expedited external review, you should complete the following steps:

Obtain documents. Collect the following documents for your external review request:

  • The external review request form packet (click here). You should use this form for both standard and expedited external reviews;
  • Release of medical records form, which is included in the external review request form packet;
  • Copy of your insurance card;
  • Copies of all determination letters and any other information that your insurer sent to you;
  • Medical records related to the condition for which you are seeking treatment;
  • Any peer review literature or clinical studies related to your requested treatment; and
  • Any additional information from your health care provider that you want the independent review organization to consider.[10]

Prepare your request. Complete the external review request form and medical release form. Be sure to include the following information:

  • The name, address, telephone number, and email address of the person filing the request (“applicant”);
  • Applicant’s relationship to the patient;
  • The name, address, telephone number, and email address of the patient, if different than applicant;
  • The name of the insurance company and name of the insured person;
  • The primary insured person’s identification number and patient identification number;
  • Whether the health plan is an individual plan, group plan through employer (and include employer’s name), or a group plan through a plan sponsor (and include the sponsor’s name);
  • The name, address, telephone number, and email address of the health care provider and name of the contact person at the provider’s office;
  • The reason for the appeal; and
  • A description of the treatment, service, drug, or procedure being denied, the date of service, and the date of denial.[11]

Submit your request. Submit your request for an external review or expedited external review and supplemental documentation within four months from the date that your insurer sent you the last determination letter. You can also fax your materials to (217) 557-8945 or email them to [email protected]. You can also mail your request to:

Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Request
320 W. Washington Street
Springfield, IL 62767[12]

After the review organization receives all of the necessary information relating to your claim, you should receive a response within the following timeframes:

  • No more than 45 days for standard external reviews;
  • No more than 72 hours for expedited external reviews; and
  • No more than seven calendar days for requested experimental or investigational treatments or services.[13]

If you are an Illinois resident and your insurer denies your coverage after the external review process or your insurer determines your claim is not eligible for external review, you can file a complaint with the Illinois Department of Insurance (“Department”).

Click here for the complaint form. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, email address, and telephone number of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • The insured’s individual identification number;
  • The name of the employer or group if it’s a group plan;
  • Claim number and date of service; and
  • The details of the complaint.

You can attach supporting documents to complaints submitted online or you can fax or mail supporting information.[14] You should 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 doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

The complaint may be submitted online here, faxed to (217) 558-2083, or mailed to:[16]

Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767

Once the Department receives your complaint, it will be assigned a file number. A copy of the complaint will be sent to your health insurer, who has 21 days to respond. An analyst will review the complaint and the insurance company’s response. The investigation will take between four and six weeks, and you will be advised of the decision.[17]

You can contact the Illinois Department of Insurance Customer Assistance Hotline at (866) 445-5364. The Department is open from 8:00 a.m. to 8:00 p.m. Monday through Saturday.