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 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 Utah law, you are entitled 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.[4] If you are requesting an expedited external review, you should ask your insurer if you can also skip the internal appeal process altogether.

You should submit your request for an external review to either your health insurer or the Utah Department of Insurance (“Department”) within 180 days of your insurer’s last denial letter.[5] You can find a copy of the Health Benefit Plan Independent Review Process request form here.

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

  • The name of the person requesting the review;
  • The name, address, telephone number, and email address of the insured;
  • The name of the insurance company;
  • Insurance identification number and type of coverage;
  • The name and telephone number of your employer;
  • Reason for denial; and
  • A description of the service or treatment in dispute; and
  • “Certification of Treating Health Care Provider for Expedited Consideration of a Patient’s Independent Review” form on page 5 of the request packet (this form is for expedited external review requests only).[6]

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

  • A signed medical records release form (included with external review request packet);
  • A copy of your insurance card or other evidence of coverage;
  • A copy of the final decision letter from your health insurer; and
  • Any additional or new information or documentation not included with your request for an internal appeal.

Submitting a standard external review. If you are requesting a standard external review, you should submit your request by fax to (801) 538-3829, by email to [email protected], or by mail to the following address:

Health Benefit Plan Independent Review Process
Utah Insurance Department
Suite 3110, State Office Building
Salt Lake City, UT 84114[7]

The external review process should take no more than 45 days after the independent review organization is assigned to your case.[9] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the independent review organization.[10]

If you are a Utah resident and your claim is denied after the external review process, you can file a complaint with the Utah Attorney General’s Office.

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, address, and telephone number of insurance company;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

Supporting documents. You should submit the following documents as supporting information:

  • 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.[11]

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

Utah Attorney General’s Office
Criminal Investigations Unit
5272 S. College Dr., Suite 200
Murray, UT 84123[12]

The Attorney General’s Office will forward a copy of your complaint to the insurance company and request a response. The insurer has ten days to respond to the complaint. The complaint process typically takes between three and six weeks to complete. The Attorney General’s Office can require the insurer to reverse its decision and provide coverage.

If you have questions regarding insurance appeals, you can contact the Utah Department of Insurance at (801) 538-3890 or (800) 439-3805 (in-state). The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

If you have questions regarding filing a complaint, you can reach the Attorney General’s Office at (800) 244-4636. The Attorney General’s Office is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.