For the seriously ill and their caregivers
Experimental and Medically Necessary Treatments
If your claim or your request for specific treatment is denied because the insurance company has determined that the treatment is experimental, investigational or not medically necessary, you have appeal rights mandated in the law. Here are the steps to take:
1. Appeal to the Health Insurer
When health services are denied because the health plan considers the service to be experimental, investigational or not medically necessary, you must first appeal the denial with your health plan unless you and your health plan agree to waive the internal appeal process.
If you are undergoing a course of treatment or your health care provider believes that an immediate appeal is warranted, you have the right to request that this appeal be conducted on an expedited basis. Expedited appeals must be decided within two business days.
2. External Appeal
If your health plan upholds its denial of your first level internal appeal, or agrees to waive the internal appeal, you will be eligible to request an external appeal.
An external appeal is a review conducted by an independent external review organization that is certified by the state and is not affiliated with your insurer.
It is important to note that an external appeal application must be sent to the Department of Financial Services within 45 days from receipt of the denial at the first level of appeal with your health plan OR 45 days from receipt of the letter from your health plan waiving the internal appeal process.
For more information on external appeal including how to get an application, please select this link.