New Hampshire

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 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 and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.[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. Under New Hampshire law, you are entitled to request an external review if your insurer denies your appeal, and the denial was based on the insurer’s belief that the recommended treatment or service:

  • Is not medically necessary,
  • Is not appropriate for your condition, or
  • Does not meet the insurer’s requirements for health care setting or level of care or effectiveness.[4]

You can request an expedited external review if your medical situation is urgent and waiting will jeopardize your health, life, or ability to function.

You should submit your request for external review to the New Hampshire Insurance Department (“Department”) within 180 days from when your insurer sent you the most recent decision.[5]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • The name, address, email address, and telephone number of the applicant;
  • The patient’s name and date of birth (if different from the applicant);
  • The name and relationship to patient of the insured;
  • The name, address, and telephone number of the insurance company;
  • The name of the claim representative handling your appeal;
  • Member identification number and claim or reference number;
  • The name and telephone number of the employer;
  • The name, address, and telephone number of your primary care provider;
  • The name, address, telephone number, and specialty of your treating health care provider; and
  • Description of the complaint; and
  • The health care provider certification form in the external review application (this form is only required for expedited external review requests.)[6]

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

  • A signed medical records release form (included in the external review form packet);
  • 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 medical records, statements from your health care provider, or other information you’d like the external review organization to consider;
  • A copy of your insurance policy; and
  • Any new information or documentation not included with your request for an internal appeal.[7]

Submitting a standard external review. If you are requesting a standard external review, you should mail the completed form and supporting documents to the following address:

New Hampshire Insurance Department
Attn. External Review Unit
21 South Fruit Street, Suite 14
Concord, NH 03301[8]

Submitting an expedited review. If you are requesting an expedited external review, you can fax your request to (603) 271-1406 or send it by overnight mail to the address above.[9]

The external review process should take no longer than 60 days.[10] If you requested an expedited external review, the process should take no longer than 72 hours.[11]

If you are a New Hampshire resident and you believe that your insurer did something illegal or unethical, you can file a complaint with the Department.

Complaint information. 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 name of insurance company;
  • Group or policy number, date of issue, claim number, and date of loss;
  • The reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[12]

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.[13]

How to submit. The complaint and supporting documents may be submitted online here, faxed to (603) 271-1406, or mailed to the following address:

New Hampshire Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301-2430[14]

Once the Department receives your complaint, a Consumer Service Officer will determine if the Department has the authority to handle your claim. If the Department does have the authority, your complaint will be forwarded to your health insurer for a response. The insurer should respond to the Department within ten business days.[15] The total investigation time varies, but most cases are resolved within 45 days. The Department can force the insurer to cover the claim, issue a citation, or fine the insurer. If the Department determines that your health insurer knowingly violated a law or regulation, it can lose its license to offer insurance in New Hampshire.

You can contact the New Hampshire Department of Insurance at (800) 852-3416. The Department is open from 9:30 a.m. to 4:30 p.m., Monday through Friday.