Rhode Island

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 of 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.
  • Request an expedited internal appeal, if applicable. You can request an expedited internal appeal if you need emergency health care services or if your life is in jeopardy.[2] Your health insurer is required to notify you of the process for requesting an expedited internal appeal with the initial denial letter.[3] You should follow those instructions closely.
  •  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.
  • File for a second level internal appeal. If the insurer denies your claim during the initial (first level) internal appeal, you may request a second level internal appeal.[4] During the second level internal appeal, you can inspect your insurer’s file on you and submit any additional documents.[5] Your health insurer should have provided you with instructions on how to request a second level internal appeal when it denied your first level appeal.[6] You should follow those instructions closely.

The first level and second level internal appeals process should take a maximum of 21 business days for each level of appeal.[7] An expedited internal appeal should be completed within two business days after the appeal is filed and the insurer receives all necessary information.[8]

During an external review, an independent third party reviews your insurer’s decision.[9] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Rhode Island law entitles you to request an external review if your insurer denies your coverage after an internal appeal.

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function. If you are requesting an external review, you should contact your insurer to determine if you can skip the internal appeal process altogether.

You should submit your request for an external review to your health insurer within 60 days from the date that your insurer sent you the final decision.[10] You must also send your insurer a check for half of any fee required.[11] The notice of denial from the second level of internal review will include information regarding the fee requirements for an external review.[12] The fee will be refunded to you if the external review agency decides in your favor.[13] You should also include any additional or new information that you did not include with your request for an internal appeal.

Your health insurer must forward your request and supporting documentation to the external review agency within five days of receiving your request for external review.[14]

The external review agency should send you its decision within ten business days from receiving the necessary documentation.[15] If you request an expedited external review, the process takes no longer than two business days.[16]

If you are a Rhode Island resident, you can file a complaint with the Rhode Island Department of Business Regulation, Insurance Division, if your claim is denied after the external review process and you believe that your health insurer has done something illegal or unethical.

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person making the complaint (“Complainant”);
  • The name of the insured individual;
  • The names of other parties involved in the dispute;
  • The name of the insurance company, insurance agency, and agent, adjuster, or appraiser;
  • The policy number, certificate number, claim number, and date of loss;
  • The type of insurance and reason for complaint; and
  • The details of your complaint.[17]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of the determination letters 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.[18]

How to submit. The complaint may be submitted online here, faxed to (401) 462-9602, emailed to [email protected], or mailed to the following address:

State of Rhode Island and Providence Plantations
Department of Business Regulation
Insurance Division
1511 Pontiac Avenue, Bldg. 69-2
Cranston, RI 02902[19]

Note that the Insurance Division does not have the authority to require an insurer to pay a claim.[20] If your case involves failure of your health insurer to pay your claim, you should contact the Rhode Island Insurance Resource, Education, and Assistance Consumer Helpline (“RI REACH”) at (855) 747-3224 to file a complaint. A representative of RI Reach will be able to assist you through the process.

Once the Insurance Division receives your complaint, it will determine whether it can handle your claim.[21] If it decides to handle your claim, it will send you an acknowledgement letter. It will also send a copy of your complaint to your health insurer for a response.[22] The insurer typically responds within three days. The Insurance Division will review the insurer’s response and conduct an investigation. Once the Insurance Division has concluded its investigation, it will send you a letter with its findings.[23]

You can contact the Rhode Island Insurance Division at (401) 462-9520. The Division is open from 8:30 a.m. to 4:00 p.m., Monday through Friday.