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. Reconsideration request;
  • 2. First level internal appeal;
  • 3. Second level internal appeal; and
  • 4. Independent external review[1].

If your insurer denies your claim for a medical reason, then your health care provider may request a reconsideration of the denial. You are not responsible for submitting the request. The request must be completed by your insurer within one working day after the insurer receives the request.[2] If your health care provider either does not request a reconsideration or is not successful, you have the right to two levels of internal appeals and possibly an independent external review.[3]

If your insurer denies your claim, you have the right to a first level internal appeal. 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.
  • 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 internal appeal, if applicable. If your health care provider believes that you require medical care sooner than it would take to go through the regular first level and second level internal appeals processes, you or your health care provider can submit a request to your health insurer for an expedited internal appeal.[4] You qualify for an expedited internal appeal if a denial of the requested treatment within 45 days would seriously jeopardize your life, health, or ability to function.[5] It should be noted that expedited internal appeals are not available for retrospective denials.[6]
  • 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. 

If the first level internal appeal is not successful, you should submit a request to your health insurer for a second level internal appeal. During the second level internal appeal, your case is reviewed by a panel of insurance company personnel.[7] You may ask for a hearing as part of the second level internal appeal, and you and your health care provider can participate in the hearing either in person or by telephone.[8]

The first level internal appeals process should take a maximum of 30 days from the date your insurance company receives your request for an internal appeal.[9] If you request a hearing during the second level appeal, your health insurer must schedule the hearing within 45 days, and the panel has five days to make their decision. If there is no hearing, your health insurer must notify you of its decision within 30 days.[10] If you requested an expedited internal review, the decision should be rendered within 72 hours after your request is received.[11]

If your insurer denies your coverage after completing the first and second level internal appeals processes, you are entitled by law to request an external review from an independent third party. This means your insurer no longer has the final say over whether to approve a treatment or pay a claim.[12]

You can apply for an expedited external review if you requested an expedited internal appeal and your request was denied.[13]

You should call or write to the Maine Bureau of Insurance (“Bureau”) to request an external review within 12 months from the date that your insurer denied the second level internal appeal.[14] You can reach the Bureau at (207) 624-7475 or (800) 300-5000 (Maine only) or by mail at:

Consumer Health Care Division
Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333.[15]

If you are requesting an expedited external review, you should immediately contact the Maine Bureau of Insurance (“Bureau”) at (207) 624-8475 or (800) 300-5000 to make your request.[16]

If the Bureau determines that you qualify for an external review, it will send you a packet of forms, including an authorization and contact sheet.[17] You should complete the forms and send them to the Bureau at the above address, along with a copy of your final determination letter and any new information and documentation not included in the internal appeals.[18].

The external review process should take no more than 30 days from the date the external review organization receives the request.[19] If you request an expedited external review, the process should take no longer than four business days after your request is received.[20]

If you are a Maine resident, you can file a complaint with the Bureau at any time during the appeals process. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The names of your employer if your health insurance is through your employer;
  • The name, address, and telephone number of the insurance company;
  • The policy, certificate, or identification number and claim number; and
  • The details of the complaint.

You can find a copy of the complaint form here. You should also submit the following supporting documents:

  • A signed medical records release form (included in the online application);
  • A copy of your insurance card;
  • Any correspondence, including emails, notices, explanations of benefits, and any other communications between you and your health insurer related to the complaint;
  • Records explaining how claim payments were calculated;
  • 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.[21]

The complaint may be submitted online here, faxed to (207) 624-8599, or mailed to:

Maine Bureau of Insurance
34 State House Station
Augusta, ME 04333

Your complaint will be assigned to a claims investigator. The investigator will contact your insurer and request a response. The health insurer has 14 days to respond, but may request an extension. It usually takes a minimum of 30 days to complete an investigation.[22] The Bureau can force the health insurer to comply with the policy, issue a citation, or fine the insurer for violations of law or regulation.

You can contact the Bureau at (800) 300-5000 or (207) 624-8475. The Bureau is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.