North Dakota

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 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 North Dakota law, you are entitled to request an external review if you are not satisfied with the outcome of your internal appeal, or if your insurer waives the internal appeal, you may request an external appeal.[4]

For most plans, you can also request an expedited external review in urgent situations. If your situation is urgent, you should contact your insurer and find out if you can skip the internal appeals process altogether and request an expedited external review immediately.[5]

You should submit your request for an external review to either your health insurer or the North Dakota Department of Insurance (“Department”) by mail to the following address:[6]

North Dakota Department of Insurance
600 E. Boulevard Ave., #401
Bismarck, ND 58505.

You must file your written request for an external review within four months from the date that your insurer sent you the final decision.[7] If you submit your request to your health insurer, your insurer will forward your request to the Department.[8] You should include any new information and documentation that you did not include with your previous request for an internal appeal with your request.

The external review process should take no more than 45 days from the date your request is accepted by the external review organization for review.[9] If you request an expedited external review, the process should take no longer than 72 hours after your request is received.[10]

If you are a North Dakota resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department. You can find a copy of the complaint form here.

Complaint information. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of the insured individual, if different than the Complainant;
  • The name of insurance company;
  • The name and address of the agent involved, if applicable;
  • Policy number and date of loss;
  • The name and address of the adjusting company, if applicable;
  • The name and telephone number of adjuster, if applicable;
  • Assistance requested from Department; and
  • The details of the complaint.

Supporting documents. You should submit the following supporting documents with y 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 health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[11]

You should not send copies of any doctor or hospital bills unless there is a problem with the bill itself.[12]

How to submit. The completed form and supporting documents should be mailed to the following address:

North Dakota Insurance Department
600 East Boulevard Avenue
Bismarck, ND 58505-0320[13]

The Department will review your complaint and attempt to resolve the issue with your health insurer. Within a week of receiving your complaint, you will receive a written acknowledgment. In most cases, an investigator will send a copy of your complaint to the insurance company and request an explanation of its position. The Department will determine within three weeks after receiving a response from the insurer whether further action is needed. A complaint can take up to 45 days to resolve, but may take longer for complex issues. The Department may require the insurer to pay your claim, refund your premium, or issue a citation or fine the company for violations of the contract or state law.

You can contact the North Dakota Department of Insurance at (800) 247-0560. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.