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 external review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to file a grievance with your health insurer.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 file a grievance.

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.[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 a grievance, 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 grievance process. Someone in his or her office might help you fill out the forms to file a grievance and draft a strong grievance letter.

Submit the appeal request. You or someone in your health care provider’s office should submit the grievance 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.

Ask for an expedited review, if applicable. You can request an expedited grievance review from your insurer if one of the following circumstances applies to you:

  • You are in the hospital;
  • Denial of services would create a risk of immediate serious harm;
  • You have a terminal illness; or
  • You are in urgent need of services.[3]

Your insurer should have provided you with its requirements for requesting an expedited internal grievance process with your initial determination letter.[4] Be sure to follow those instructions.

  • 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 grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.
  • Complete additional levels. Your health insurer may require two or more levels of internal review in the grievance process.[5] You should check your insurance policy, benefits booklet, and any information you received with your determination letter from your health insurer to ensure that you follow the process your health insurer requires.[6]

The grievance process should take a maximum of 30 business days, regardless of how many internal levels of review your health insurer requires.[7]

An expedited grievance review should take no longer than 48 hours once your physician certifies that there is a substantial risk of immediate harm if you are not provided the service or treatment or within five days if you are terminally ill.[8] If you are in the hospital, your health insurer must provide you with a decision about inpatient care prior to your discharge from the hospital.[9]

Under Massachusetts law, if your insurer fails to provide a decision within the allotted time periods, the insurer must cover the service or treatment you requested.[10]

During an external review, an independent third party reviews your insurer’s decision.[11] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

Under Massachusetts law, you are entitled to request an external review in the following circumstances:

  • Your insurer denies your coverage after an internal grievance review within the allotted timeframe;
  • There is a serious and immediate threat to your health (in this case, you should apply for an expedited external appeal).[12]

You can file a request for an expedited external review at the same time that you request an expedited internal grievance review.[13]

You must file your request for an external review with the Massachusetts Office of Patient Protection (“Office”) within four months of the date on your insurer’s most recent decision.

Information. You can find a copy of the external review request form here.[14] You should include the following information:

  • Patient’s name, address, telephone number, and date of birth;
  • Policyholder’s name;
  • Patient’s insurance identification number;
  • Name of health insurance company;
  • Name of the person at the insurance company involved with the appeal;
  • Description of the problem;
  • Name, address, and telephone number of the health care provider who ordered the service which was denied; and
  • Information regarding your health history, if you want that information to be considered by the external review agency.[15]

Supporting documents. You should also include the following supporting documents with your application:

  • A copy of all determination letters from your health insurer;
  • A signed medical records release form (included with request packet);
  • A copy of your insurance card; and
  • Any medical records, health care provider statements, and other information for the external review agency to consider.

If you are requesting an expedited external review, you should also include the following documents with your application:

  • The “Request for Expedited Review” section on page 9 of the external review request packet;[16] and
  • The “Certification for Expedited External Review” form included on pages 10 – 11 of the external review request packet.[17]

Filing fee. You must include a $25 filing fee with your application. The fee is payable by check or money order.[18] If the external review is resolved in your favor, the Office will refund your payment. If the fee would create an extreme financial hardship for you, you can request a waiver of the fee by completing a fee waiver form. The form is on page 8 of the external review request form, which can be found here. The form contains a chart, which explains what qualifies as “extreme financial hardship.”

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request and supporting documents by fax to (617) 624-5046 or by mail to the following address:[19]

Office of Patient Protection
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109

How to submit an expedited external review request. If you are requesting an expedited external review, you should fax your request and supporting documents to the Massachusetts Office of Patient Protection at (617) 624-5046.[20]

The external review process should take no more than 45 days from the date the external review agency receives the request. If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[21]

If you are a Massachusetts resident and your insurer still denies your claim after the external review process, you can file a complaint with the Massachusetts Division of Insurance (“Division”).

Complaint information. You can find the complaint form here. 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 insurance company;
  • The state where the insurance plan was purchased;
  • The group number, certificate number, policy/ID number, claim number, and date of loss; and
  • The details of the complaint.

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 health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[22]

You can submit your complaint and the supporting documents by faxing them to (617) 753-6830 or mailing them to the following address:

Office of Consumer Affairs and Business Regulation
Division of Insurance
1000 Washington Street, Suite 810
Boston, MA 02118-6200[23]

The Division will provide a copy of your complaint to your health insurer and attempt to resolve the issue. The Division may negotiate a settlement or hold an administrative hearing.[24] If the Division determines that your health insurer has violated a law or regulation, the Division can make your insurer pay a penalty.[25]

You can contact the Massachusetts Division of Insurance at (617) 521-7794 or (877) 563-4467. The Division is open from 8:45 a.m. to 5:00 p.m., Monday through Friday.