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 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.
  • 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 45 days of receiving your request.[2] If you requested an expedited internal review, your insurer should provide you with a decision within 72 hours for your request.[3]

During an external review, an independent third party reviews your insurer’s decision.[4] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Wyoming law, you are entitled to request an external review if your insurer denied your coverage after an internal appeal and the denial was based on lack of medical necessity.[5]

You are also entitled to an expedited external review in circumstances where a delay of 45 days would jeopardize your life, health, or ability to regain function or if your claim concerns a request for an admission, availability of care, or continued stay or services for which you received emergency services but have not been discharged from a health care facility.[6] You can request an expedited external review at the same time that you file for an expedited internal review.[7]

You should submit your request for an external review to your health insurer within 120 days from when your insurer sent you the final decision.[8] Your health insurer must provide you with information regarding how to request an external review with your denial letter. You can use the insurance company form or the Wyoming Insurance Department form, which can be found here.[9]

Upon receipt of your request, your health insurer will forward your request to an independent review organization for review and notify the Insurance Department.[10]

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

  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • Subscriber or member number and insurance claim or reference number;
  • The name and address of your treating health care provider and the name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • Brief description of decision in dispute; and
  • The health care provider certification in the external review packet (This form is only required for expedited external reviews).[11]

Filing fee. You must submit a $15 filing fee by check or money order made payable to the Wyoming State Treasurer with your request. The fee may be waived for financial hardship.[12] If you believe you have a financial hardship, complete the “Certification of Qualification for Fee Waiver” in the external review request form.[13] If you complete that section, do not submit the filing fee.[14]

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

  • A copy of the denial letter from your health insurer;
  • A copy of your insurance card or other evidence showing coverage; and
  • Any new information and documentation that you had not included with your prior request for an internal appeal.

The external review process should take no more than 45 days after the external review organization receives your request.[14] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[15]

If you are a Wyoming resident and have completed the internal appeal and external review processes, you can file a complaint with the Wyoming Department of Insurance (“Department”).

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, if different than the Complainant;
  • The name, address, and telephone number of insurance company;
  • The name and title of any person you’ve spoken with about your claim at the insurance company as well as the date and place;
  • Policy number, group name or number, claim number, date of coverage, 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.[17]

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

Wyoming Insurance Department
106 E. 6th Avenue
Cheyenne, WY 82001[18]

The Department will investigate your complaint and attempt to reach a resolution with your health insurer.

You can contact the Wyoming Insurance Department at (307) 777-7401. The Department is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.