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 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.

The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment. The internal appeal must be completed within a maximum of 60 days if you already received services or treatment.[2]

During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to an external review if your insurer denies your coverage after an internal appeal. Additionally, if your medical situation is urgent and waiting will jeopardize your life or ability to function, you are entitled to an expedited external review.[4]

You must submit your request for external review to the Nebraska Department of Insurance (“Department”) within four months from when your insurer sent you the final decision.[5] Your health insurer should have provided you with a copy of the external review request form with your determination letter.[6] You can also find a copy of the external review request form here.

Information. You should include the following information with your request:

  • Name of applicant;
  • Name, address, and telephone number of the insured person;
  • Name of the patient;
  • Name, address, and telephone number of the health insurer;
  • Insurance identification number, claim or reference number;
  • Employer name and telephone number;
  • Name and address of your treating physician or health care provider;
  • The name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • The reason for denial;
  • Brief description of the claim; and
  • Description of the health care service or treatment in dispute.[7]

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

  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of your insurance policy; and
  • Any additional information or documentation not included with your request for an internal appeal.[8]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

Nebraska Department of Insurance
P.O. Box 82089
Lincoln, NE 68501-2089[9]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Department at (877) 564-7323 for instructions on the fastest way to submit your request and supporting documentation.[10]

The external review process should take no longer than 45 days from when your request is received.[11] If you request an expedited external review, the process should take no longer than four business days after your request is received.[12]

If you are a Nebraska resident and you still lack 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 of insurance company;
  • The name of the agent or adjuster;
  • Policy or claim number and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[13]

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 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.[14]

How to submit. The complaint may be submitted online here or mailed to the following address:

Nebraska Department of Insurance
941 O Street, Suite 400
P.O. Box 82089
Lincoln, NE 68501-2089 [15]

Once your complaint has been submitted, you will receive notification that the Department is investigating your claim.[16] A copy of your complaint will be sent to your health insurer, and the Department will request certain information from the insurer.[17] Your health insurer has 15 business days to respond to the Department’s request for information. An investigator will review information received from your insurer and provide you with notice of the outcome.[18] If the Department determines that your insurer has committed a violation, your complaint will be referred to the Legal Division for further review.[19] The Department can also force the insurer to comply with the policy.

You can contact the Montana Department of Insurance at (800) 332-6148 or (406) 444-2040 (in Helena). The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.