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 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 Oklahoma law, you are entitled to an external review if your insurer denied your coverage after an internal appeal.

You can request an expedited external review if you need immediate medical care.[4] You should contact your insurer to determine whether you can also skip the internal appeal process altogether when requesting an expedited external review.

You are not eligible for external review if the requested treatment is not covered by your health plan or if your dispute involves a question of administration, such as whether you paid your premium on time.[5]

You should submit your request for external review to the Ohio Department of Insurance (“Department”) within four months from the date that your insurer sent you the final decision.[6]

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

  • The name of the applicant;
  • The name of the insured;
  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • Insurance identification number and insurance claim/reference number;
  • The name and telephone number of the employer;
  • The name and address of your treating healthcare provider;
  • The name and telephone number of the contact person with your healthcare provider;
  • Your medical record number;
  • The reason for the denial;
  • A description of the disputed decision; and
  • The health care provider certification form found on page 6 of the request packet (this step is only for expedited external review requests).[7]

Supporting documents. You should also include the following documentation:

  • A signed medical record release form (included in the external review form packet);
  • A copy of your insurance card;
  • A copy of the final determination letter from your health insurer;
  • A copy of your certificate of coverage or insurance policy benefit booklet; and
  • Any additional or new information and 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:

Oklahoma Insurance Department
External Review
Five Corporate Plaza
3625 NW 56th Street, Suite 100
Oklahoma City, OK 73112-4511[9]

Submitting an expedited review. If you are requesting an expedited external review, you should call the Department at (800) 522-0071 or (405) 521-2828 to receive instructions on the fastest way to submit your request.[10]

The external review process should take no more than 45 days once the Department determines that your request is eligible for external review.[11] If you requested an expedited external review, the process should take no longer than four business days after your request is received.[12]

If you are an Oklahoma resident your claim is denied 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, address, and telephone number of the insured individual, if different than the Complainant;
  • The name and address of insurance company;
  • The policy number and effective date of the policy;
  • The name, address, and telephone number of the agent;
  • The name, address, and telephone number of the adjuster; and
  • The details of the complaint.[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 health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[14]

How to submit. The complaint may be submitted online here, faxed to (405) 521-6652, or mailed to the following address:

Oklahoma Insurance Department
Five Corporate Plaza
3625 NW 56th, Suite 100
Oklahoma City, OK 73112[15]

Once your complaint is received, the Department will assign it to a consumer assistance or claims analyst, and you will receive a letter of acknowledgement.[16] The analyst will contact your health insurer, which has 30 days to respond.[17] The analyst will contact you when he or she makes a decision.[18] The Department can force the health insurer to comply with the policy provisions, issue a citation or fine the company.

You can contact the Oklahoma Insurance Department at (800) 522-0071 (in-state only) or (405) 521-2991. The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.