West Virginia

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 West Virginia law, you are entitled to request an external review if your insurer:

  • Denies your internal appeal; or
  • Does not provide you with a decision on your internal appeal within the required timeframe.[4]

You can also request an expedited external review if your life or health would be jeopardized by waiting 30 to 60 days.[5] You may request an expedited external review simultaneously with an internal appeal.[6]

You should submit your request for external review to the West Virginia Offices of the Insurance Commissioner (“Offices”) within 180 days from when your insurer sent you the final decision.[7] You can find a copy of the Independent External Review of Healthcare Decision  form here.

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

  • The name, address, email address, and telephone number of the insured;
  • The patient’s name;
  • The name and telephone number of your employer;
  • The name, address, and telephone number of the insurance company;
  • The name of the contact person at your insurance company;
  • The name, type of provider, address, and telephone number of your health care provider;
  • A description of the dispute; and
  • An “Expedited Appeal Certification by Treating Healthcare Provider” form found in the external review packet (This form is for expedited external review requests only).[8]

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

  • A signed medical records release form (included in the external review request packet);
  • A copy of your insurance card or other evidence of insurance coverage;
  • A copy of your denial letter;
  • A copy of your certificate of coverage or insurance policy benefit booklet; and
  • Any medical records, statements from your health care provider, and any additional or new information and documentation you’d like the external review organization to review.[9]

How to submit a standard external review request. If you are requesting a standard external review, you should submit your request to the following address:

Independent External Review
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540[10]

How to submit an expedited external review request. If you are requesting an expedited external review, you should call (304) 558-3386 to ask for instructions on the quickest way to submit your request.[11]

The external review process should take no more than 45 days after the Offices of the Insurance Commissioner receives your request.[12] If you request an expedited external review, the process should no longer than 72 hours after your request is received.[13]

If you are a West Virginia resident and your insurer denies your coverage after the external review process, you can file a complaint with the West Virginia Offices of the Insurance Commissioner Consumer Services Division (“Division”).

Complaint information. You can find a copy of the complaint form here. 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 patient and name of the insured, if different than the Complainant;
  • The names of other parties involved in the claim;
  • The name of insurance company;
  • The type of coverage, policy number, claim number, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[14]

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.[15]

How to submit. The complaint and supporting documents can be faxed to (304) 558-4965 or mailed to the following address:

Consumer Services Division
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540[16]

Once the Division receives your complaint, it will assign it to an insurance specialist who will send an acknowledgement letter to you. It will contact the insurance company, who then has 15 working days to respond. After the response is received, the specialist will review the insurer’s response and any documents the insurer has submitted with the response (such as a copy of the policy or certificate of insurance) to determine if the insurer is handling your claim appropriately. If no violations are evident, the specialist will notify you that he or she is closing the complaint. If the specialist determines that there may have been a violation, the complaint is then turned over to the legal department for further action.

You can contact the West Virginia Offices of the Insurance Commissioner at (888) 879-9842.  The Offices are open from 8:00 a.m. to 5:00 p.m., Monday through Friday.