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 complete the following steps within 60 days of receiving your determination letter:

  • 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.
  • Request an expedited appeal, if applicable. If waiting 30 days to receive your requested treatment would jeopardize your health, safety, or ability to regain function, you may request an expedited appeal. You should contact your insurer and ask for instructions on how to complete this step.
  • 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.[2] If your health care practitioner requests an expedited appeal, the process should take no more than 72 hours.[3]

During an impartial review (also known as an external review), an independent third party reviews your insurer’s decision.[4] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to request an impartial review if your insurer denies your internal appeal[5] You can request an expedited impartial review if one of the following circumstances applies:

  • You are hospitalized;
  • Your health care provider determines that your situation is urgent;
  • The treatment denial could seriously jeopardize your life, health, or ability to regain maximum function;
  • Your health care provider believes you would be subjected to severe pain that cannot otherwise be adequately managed without the requested treatment; or
  • The requested treatment is experimental or investigational and your health care provider certifies in writing that the treatment will be significantly less effective if not initiated promptly.[6]

You can request the expedited impartial review while you request the expedited internal appeal, if at least one of the above circumstances applies.[7] Please note that if you request an expedited appeal and the independent review entity issues a decision in favor of your insurer, you may be required to pay a $25 fee.

Request to Insurer for Impartial Appeal. You should send your request for an additional impartial appeal to your insurer if your insurer denied your claim because it deemed your requested treatment or services not medically necessary or experimental/investigational.[8]

The appeal must be made  within four months of receiving your upheld denial letter and you should  send the following documents to the insurer:

  • A written request for an impartial review; and
  • A signed medical records release form, which your insurer should have provided to you with your denial letter.[9]

Your insurer will then send your request to an independent review entity. The insurer will notify you when the external impartial medical review is assigned to the entity.[10]

Request to the Department. If your insurer denied your claim because your plan (1) placed limitations on the requested treatment or services; or (2) did not cover your requested treatment or services, you should submit a request for an impartial review to the Kentucky Department of Insurance, Health and Life Division (“Department”). You should  send the following documents to the Department:

  • A written request for an impartial appeal;
  • A copy of the denial letter from your insurer; and
  • A statement containing the reason you believe coverage should be provided.[11]

You should mail these documents to the following address:

Kentucky Department of Insurance
Health and Life Division
Attn: Coverage Denial Coordinator
P.O. Box 517
Frankfort, KY 40602[12]

The Coverage Denial Coordinator will request information from your insurer and determine whether the service, treatment, drug, or device meets one of the following:

  • Is specifically excluded under your plan and the insurer’s denial was correct;
  • Is covered and will instruct your insurer to pay the claim; or
  • Requires the resolution of a medical issue and will instruct your insurer to either cover the claim or give you the opportunity to request an external review.[13]

Request to Consumer Protection Division for Impartial Review. If your health insurer denied your claim because you failed to follow the requirements or procedures set out in your insurance benefits handbook, or you have a general complaint, you should submit a request for impartial appeal to the Kentucky Department of Insurance, Consumer Protection Division. You can submit your request by completing an online form here or mailing your request to the following address:

Kentucky Department of Insurance
Consumer Protection Division
P.O. Box 517
Frankfort, KY 40602[14]

In your request, you should state your reason for appealing your insurer’s determination and submit any copies of documents that support your position.

The impartial review process should take no more than 45 days. If you requested an expedited impartial review, the process should take no longer than 72 hours after your request is received.[15]

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

Complaint information. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • Policy number, group number, and the name and address of the agent/adjuster; and
  • The details of the complaint.

Supporting documents. You should 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 impartial 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]

How to submit. The complaint may be submitted online here, faxed to (502) 564-2728, or mailed to:

Kentucky Public Protection Cabinet
Department of Insurance
P.O. Box 517
Frankfort, KY 40602-0517[17]

Once the Department receives your complaint, it will send a copy to your insurer who then has 15 calendar days to respond. A typical case should be resolved within 30 days.[18]

You can contact the Kentucky Department of Insurance at (800) 595-6053 (for Kentucky residents only) or (502) 564-6034 and ask to speak with a Consumer Complaint Investigator. The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.