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 a first level 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 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.
  • 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.
  • Second level appeal. If your insurer denies your claim after the first level appeal, you may have to request a second level internal appeal. Your health insurer must notify you if it requires a second level appeal. It will provide you with instruction how to request the appeal and the deadline for filing the request.[2] During a second level internal appeal, you will have the right to appear in person before your health insurer’s representatives and the right to present your case directly to such representatives.[3]

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 have been denied for reimbursement.[4]

If you seek a second level of internal appeals, the process should take no more than 15 business days if you have not yet received the requested service or treatment and no more than 30 days if you have received the service or treatment but have been denied for reimbursement.[5]

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

  • You requested an internal appeal but your insurer did not give you a decision within 60 days;[7] or
  • Your insurer denied you coverage after you requested an internal appeal.[8]

You can skip the internal appeals process and request an expedited external review if you have an emergency medical condition.[9] Your condition is considered an “emergency medical condition” if:

  • Your condition is sudden, unexpected, and requires immediate medical attention;
  • If waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your health insurer has determined that the requested treatment is experimental or investigational; or
  • Your health care provider certifies in writing that the requested treatment would be significantly less effective if not initiated promptly.[10]

If insurer has denied your health claim, you can submit a request for an independent medical review to the Department of Insurance within 120 days of receiving a final decision from your insurer.[11] You should contact the Kansas Department of Insurance (“Department”) at (800) 432-2484 to request a copy of the Independent Medical Review request form.[12] Note that the following plans are not eligible for independent medical review:

  • Medicare or Medicare supplement
  • Medicaid
  • Federal employee plans
  • Workers’ compensation
  • Self-insured employer plans

Supporting documents. You should include the following supporting documents with your request if your plan is eligible:

  • A letter summarizing your dispute,
  • Any new documentation that you had not included with your previous request for an internal appeal;
  • Copies of relevant medical records;
  • Your health care provider’s professional recommendation;
  • Consulting reports from other health care professionals and other documents submitted by your health insurer, you, or your health care provider;
  • Your insurance policy; and
  • All correspondence sent to you by your insurer[13]

How to submit a standard external review request. To request a standard external review, mail the form and supporting documentation to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612

How to submit an expedited external review request. To request an expedited external review, contact the Department at (800) 432-2484 and ask for an independent medical review coordinator to help you with the process.[14]

Within ten business days of receiving your request for external review, the Department will determine whether your situation qualifies for review by an independent review organization.[15] If your request is approved, the Department will forward your request to an independent review organization for further examination.[16]

The external review process should take no more than 30 business days after receiving your request for external review. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[17]

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

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of insurer;
  • Policy number, claim number, and date of loss; and
  • The reason for and details of the complaint.[18]

Supporting documents. You should also submit the following supporting documents with your complaint:

  • 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.[19]

How to submit. The complaint and supporting documents can be submitted online here, faxed to (785) 296-5806, or mailed to:

Kansas Department of Insurance
Attn: Consumer Assistance Division
420 SW 9th Street
Topeka, KS 66612-1678[20]

Once the Department receives your complaint, it will forward a copy to your insurance company for a response and send you a letter of acknowledgement.[21] If the health insurer has violated a law or regulation, the Department will request that the insurer take corrective action.[22]

You can contact the Kansas Department of Insurance at (785) 296-7829 or (800) 432-2484. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.