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 file a grievance.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, 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 file your grievance.

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 a grievance, 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 grievance process. Someone in his or her office might help you fill out the forms to file a grievance and draft a strong appeal letter.

Submit the appeal request. You or someone in your health care provider’s office should submit the grievance 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.

Request an expedited grievance, if applicable. You can file an expedited grievance if one of the following circumstances applies:

  • Waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your pain cannot adequately be managed without the requested service or treatment; or
  • Your physician determines that your grievance should be treated as an expedited grievance.[2]

You can file a request for an expedited grievance in the same way as you would file for a standard grievance.

The grievance process should take a maximum of 30 days, although your insurance company can extend that time period for an additional 30 days.[3] An expedited grievance must be resolved within 72 hours.[4]

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say whether to approve a treatment or pay a claim. Under Wisconsin law, you are entitled to request an external review if your insurer denies your coverage after a grievance.[6]

You can also request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function. You should contact your insurer and ask whether you can also skip the grievance process altogether when requesting an expedited external review.

Your health insurer should have provided you with instructions on how to request an external review with your final adverse determination letter.[7] You should follow those instructions closely. Be sure to submit your request for an external review to your insurer within four months from receiving the final decision letter.[8] You should include any new information and documentation that you did not include when you filed your grievance.

For expedited external review requests, you should submit your request to your health insurer and the independent review organization simultaneously.[9] Your health insurer is required to provide you with information on how to file this request.[10]

Once your request is received, your insurer will send the request and all relevant medical records and documentation to an independent review organization.[11]

The external review process should take no more than 40 days from the date you submit your request.[12] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[13]

If you are a Wisconsin resident and your claim is denied after the external review process, you can file a complaint with the Wisconsin Office of the Commissioner of Insurance (“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 of the insured individual, if different than the Complainant;
  • The name of your employer;
  • The name of the insurance company;
  • The state where the insurance plan was purchased;
  • The policy/certificate number, claim number, type of insurance, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

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 and supporting documents may be submitted online here, faxed to (608) 264-8115, or mailed to the following address:

Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873

If you are sending your complaint by FedEx, UPS, or overnight mail, you should send it to the following address:

Office of the Commissioner of Insurance

125 South Webster Street
Madison, WI 53707-3474[15]

The Office will send your complaint to your health insurer and require it to provide an explanation for its actions. Your insurer will have 20 days to respond. The Office will then review the health insurer’s response and require it to either fix the problem or work with you and your health insurer to resolve the issue.[16] The Office may require the insurer to comply with the policy, issue a citation, or fine the company.

You can contact the Wisconsin Office of the Commissioner of Insurance at (800) 236-8517 (in-state) or (608) 266-0103. The Office is open from 7:45 a.m. to 4:30 p.m., Monday through Friday.