Minnesota Commerce Commissioner Mike Rothman wants Minnesotans to know that help is available if a health insurance company denies their claim for coverage.
Under federal and state law, consumers have the right to appeal an insurance company’s denial of coverage for medical treatment. This includes both retrospective denials (refusal to pay for treatment that has already been performed) and prospective denials (refusal to authorize requested treatment).
“If an insurance company denies coverage, consumers need to know that it doesn’t have to end there,” said Rothman. “You have the right to appeal, first through the insurance company’s internal appeals process and then through an independent external review arranged by the Commerce Department. This is an important consumer right and patient protection.”
Rothman said that, by law, insurance companies must provide policyholders with information about their right to appeal. He provided a general outline of how the appeals process works:
You should first contact your insurer and ask for more information about why your claim was denied. If you disagree, then you should follow the company’s process for submitting a written internal appeal.
After you submit a formal appeal, the company must provide a written decision within 30 days, though extensions are allowed under certain circumstances.
If the insurer continues to deny coverage, you have the right to appeal the decision to an external review arranged by the Commerce Department. (If you have an HMO plan, the Minnesota Health Department arranges the external review.)
The external review request must be made within six months of the internal appeal decision. In an urgent health situation, an external review request can be made at the same time as the internal appeal.
For the external appeal, the Commerce Department will work with an impartial independent reviewer to determine if the denial was justified.
If the denial is overturned, the decision is binding on the insurance company and it must provide the coverage to you. If the insurer’s denial is upheld, you still have the right to take the issue to court.
The Commerce Department does not have jurisdiction over coverage provided by Medicare, Medicaid or an employer’s self-funded health plan. In most cases, you still have the right to appeal, but you should refer to your health plan information for details.
A recent national survey by Consumer Reports found that 72 percent of people did not know if they have a right to appeal to the state or an independent medical expert if their health plan refuses coverage they think they need. And 87 percent did not know which agency in their state handles complaints about health insurance.
"I want all Minnesotans to know that if you have a dispute about coverage with your health insurance company, the Commerce Department is here to help,” said Rothman.
Commerce is here to help
If you have questions or concerns about a health insurance company’s denial of coverage, contact the Commerce Department’s Consumer Services Center by email at firstname.lastname@example.org
or by phone at 651-539-1600 or 800-657-3602 (Greater Minnesota).