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 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. Your request must be submitted within 180 days of receiving notice that your claim for treatment or service has been denied.[2] 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.
  • Expedited internal appeal. You can file a request for an expedited internal appeal if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function or if your treating physician certifies that you may experience pain that cannot be adequately treated without the requested service or treatment.[3] You can submit your request in the same manner as a standard internal appeal request.

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.[4] An expedited internal appeal must be decided within 72 hours.[5]

During an external review, an independent third party reviews your insurer’s decision.[6] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Louisiana law, you are entitled to request an external review if your insurer:

  • Has not sent you a decision on your internal appeal within 30 days;[7] or
  • Denies your internal appeal.[8]

You can also request an expedited external review if waiting 30 to 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function and you have also filed a request for an expedited internal appeal.[9]

You must submit a written request for a standard external review directly to your health insurer within four months of your insurer’s last decision.[10] However, if you are requesting an expedited external review, you should submit your request to your health insurer as soon as possible.[11] You should include any new documentation or information with your request for a standard or an expedited external review that you did not previously include with your request for an internal appeal.

Once your insurer receives your request, it will ask the Louisiana Department of Insurance (“Department”) to assign the request to an independent review organization.[12] You will then receive contact information for the review organization.[13]

Once an independent review organization receives notice that it will conduct your appeal, it will select one or more clinical peers to conduct the standard or expedited review.[14] A clinical peer is a licensed physician or other health care professional in the same or similar specialty that typically manages the medical condition or treatment under review.[15] The external review process should take no more than 45 days from the date the independent review organization receives your request.[16] If you request an expedited external review, the process should take no longer than 72 hours after your request is received by the health insurer.[17]

If your claim involves an experimental or investigational treatment, the external review organization must provide written notice of its decision within 20 days of receiving the clinical peer’s opinion in a standard external review and within 48 hours in an expedited external review.[18]

If you are a Louisiana resident and your insurer denies your coverage after the external review process, you can file a complaint with the 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 of the insured individual, if different than the Complainant;
  • The name and address of insurance company;
  • The name of the employer, if it’s a group policy;
  • The policy number, group number, claim number, and date of loss or date of claim;
  • The reason for your complaint and a description of the problem; and
  • What you consider to be a fair resolution.

Supporting documents. 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 correspondence between you and the insurance company;
  • 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 may be submitted online here or mailed to the following address:

Louisiana Department of Insurance
P.O. Box 94214
Baton Rouge, LA 70804-9214[20]

After receiving your complaint, the Department will send you an acknowledgement letter, which will include your file number and the name of the compliance officer in charge of investigating your complaint.[21] The compliance officer will send a copy of the complaint to your health insurer and request a response. If the Department is unsatisfied with the insurer’s response, the Department will continue the investigation. If the health insurer violated a law or regulation, the Department will take administrative action against the insurance company.[22] The average complaint usually takes 45 days to resolve.[23] You will receive periodic updates about the status of your complaint, or you can check the status online here.[24]

You can contact the Louisiana Department of Insurance at (225) 342-5900 (local) or (800) 259-5300.  The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.