When your health plan refuses to pay for a prescription, your insurer has to explain in writing why it denied the claim and let you know how you can dispute the decision, so look for both in the letter and on your Explanation of Benefits. Then work out the day that letter reached you, because the time you have to appeal to your insurer, called an internal appeal, is counted from the day you received it.
Can anyone above your insurance company look at the refusal?
For some refusals, an independent reviewer can decide whether your plan pays. That reviewer either upholds your insurer's decision or decides in your favor, and your insurer is required by law to accept the reviewer's decision. Whether your refusal can get that far depends on the reason your insurer gave. External review is open to any denial that involves medical judgment where you or your provider may disagree with the plan, to any denial resting on a determination that a treatment is experimental or investigational, and to a cancellation of coverage based on the insurer's claim that you gave false or incomplete information when you applied.
Any refusal can go back to the insurer first. You can file an internal appeal whenever your plan will not provide or pay some or all of the cost of care you believe should be covered. A plan might refuse for reasons such as these:
- the benefit is not offered under your plan
- your medical problem began before you joined the plan
- you got care from a provider or facility outside the plan's approved network
- the service or treatment is "not medically necessary"
- the service or treatment is "experimental" or "investigative"
- you are no longer enrolled in the plan, or no longer eligible to be
- the insurer is canceling your coverage back to the date you enrolled, because it claims you gave false or incomplete information when you applied
If the reason in your letter does not fall clearly into one of the three kinds open to external review, the internal appeal is still open to you. If you cannot tell which kind yours is, ring your insurer on the phone number printed on your insurance card and ask whether the refusal can go to external review.
If the refusal came from Original Medicare, a Medicare Advantage or other Medicare health plan, or a Medicare drug plan, the route is different: the appeals process varies with the kind of coverage you have and generally runs through 5 levels. If you disagree with the decision at one level, you can usually go to the next, and each level's decision letter carries instructions for moving on. A Medicare plan must tell you in writing how to appeal, and its contact information is generally on your plan membership card. The time limits in the next section are for other health plans, so on Medicare, follow the written instructions your plan or your decision letter gives.
How long you have to appeal, and how long your insurer has to answer
You have 180 days, which is 6 months, to file an internal appeal, counted from the day you received word that your claim was denied, so write that day down now.
Your insurer and the outside reviewer have time limits of their own for each step of an internal appeal and an external review:
| Step | Who acts | Time limit |
|---|---|---|
| Telling you in writing that the claim is denied, and why | Your insurer | 15 days if you are seeking prior authorization for a treatment, 30 days for services already received, 72 hours for urgent care |
| Filing the internal appeal | You | 180 days from the day you received word of the denial |
| Deciding the internal appeal | Your insurer | 30 days for a service you have not received yet, 60 days for one you already received |
| Filing a written request for external review | You | 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied |
| Deciding a standard external review | The external reviewer | As soon as possible, no later than 45 days after the request is received |
| Deciding an expedited external review | The external reviewer | As soon as possible, and no later than 72 hours after the request is received, or sooner if the medical urgency of the case requires |
At the end of the internal appeal, your insurer must give you a written decision, and if it still refuses, that final decision must tell you how to ask for an external review. Your Explanation of Benefits or that final denial also gives the contact information for the organization that will handle your external review. Your state may run an external review process that meets or goes beyond the federal consumer protection standards, and where it does, insurers in your state follow that process.
If the timeline for the standard process would seriously jeopardize your life or your ability to regain maximum function, you can file an expedited appeal, and in that urgent situation you can ask for an external review at the same time, without finishing the insurer's own process first. A final decision on the expedited appeal must come as quickly as your medical condition requires, and no later than 4 business days after your request is received; it can be given verbally, as long as it is put in writing no more than 48 hours later. An expedited external review runs on its own clock, the 72 hours in the table. If that describes your situation, ring your insurer today on the number on your insurance card to ask for an expedited appeal, contact the organization your Explanation of Benefits names for external review today as well, and ask your prescriber's office for a letter from the doctor to send with both requests.
Who can write the appeal, and what goes in it
You do not need to write the appeal yourself, and a plain letter can take the place of your insurer's forms. The Consumer Assistance Program in your state can file an appeal for you, and that program or your state's Department of Insurance may be able to help you file an external review. For an external review you may also appoint a representative, such as your doctor or another medical professional who knows about your medical condition. If you file it yourself, complete the forms your insurer requires, or write to your insurer with your name, claim number and health insurance ID number, and send any other information you want the insurer to consider, such as a letter from your doctor.
On Medicare, free, personalized health insurance counseling comes from your local State Health Insurance Assistance Program, whose phone number you can get at shiphelp.org, and a trusted family member or friend who is helping you can be appointed as your representative. Before you start a Medicare appeal, you can ask your provider or supplier for any information that would make the appeal stronger.
Whoever files it, keep copies of everything about the claim and the refusal, including:
- the Explanation of Benefits forms or letters showing what payment or services were denied
- the request for an internal appeal that you sent to your insurer
- any documents with more information that you sent, such as a letter or other information from your doctor
- any letter or form you had to sign so that your doctor or anyone else could file the appeal for you
- notes from every phone conversation with your insurer or your doctor about the appeal, with the day, the time, the name and title of the person you talked to, and what was said
Keep the originals and send copies, with two exceptions. The original request for an internal appeal, and the original request to have someone else, such as your doctor, file it for you, are the ones your insurer needs, so make your own copies of those two before you send them.
If the case reaches external review, the cost depends on who runs it. Under the federal process run by the Department of Health and Human Services there is no charge, and an independent review organization or a state process may charge you a fee per external review, capped at the amount the page sets.
Getting treatment while the appeal is open
If the refused prescription was for weight care, it is one treatment among several. Health care professionals most often treat overweight and obesity by helping you adopt lifestyle changes, and in some cases other treatments, such as weight-loss medicines or weight-loss surgery, can be helpful, and some people are referred to a specialist or a team trained in weight management. Ask your prescriber which of those might fit you while the appeal runs, and call your insurer to ask which of them your plan covers.
Some websites sell medicines that are dangerous or even deadly, so if a seller offers you the medicine for less in the meantime, check with your state board of pharmacy that the seller is licensed before you pay anything, and treat a price that seems too good to be true as a warning sign (see Is a cheap injection from a private seller safe to buy?).
NicoCares does not bill insurers. If you are considering it while the appeal is open, a doctor licensed where you live reviews your intake answers, decides whether treatment is right for you, and tells you plainly if you are not a good candidate.
