Have you been denied access to the treatment you need to manage your health condition? AfPA’s guide, “How to Deal with an Insurance Denial,” outlines how you can file an insurance complaint in your state.
Shared decision-making and a trusted physician-patient relationship are cornerstones of patient-centered care. Sometimes, however, health insurers can disrupt care by delaying or denying access to physician-prescribed medications. Patients can appeal their insurance company’s denial. They also have options when those appeals don’t resolve the problem. Every state oversees health plans and can act as a liaison between insurance companies and the people they serve. If you have been denied access to treatment, you can file a complaint.
First try to solve the problem by following your insurance company’s appeals process. You must file your appeal within six months of receiving notice that your claim was denied. At the end of the internal appeals process, your insurance company must provide you a written decision.
If the insurance company’s final decision is unsatisfactory, you have the right to take your appeal to an independent third party for review. This is called external review.
See this state list maintained by the Department of Health and Human Services’ Center for Consumer Information & Insurance Oversight to learn more about your state’s external review.
There are a variety of reasons you might file a complaint, such as:
State-specific links for filing a complaint are available at allianceforpatientaccess.org.
Be prepared to provide the following information:
If filing a complaint does not resolve the problem, you can seek arbitration, if that is an option in your insurance policy. You may also consider filing a legal claim against your insurer in court.
A little perseverance can go a long way toward ensuring patient-centered care.
