If your claim was denied
You can appeal an insurance company's decision to deny a claim or a decision to pay less than the amount billed. The Insurance Division can explain the appeals process. Call one of our insurance experts or file a complaint to get help. Here's an overview.
Complaint and appeals process
- Your insurance company must acknowledge nonemergency complaints and appeals within seven days.
- Your insurance company must make a decision and respond within 30 days.
- If your insurance company needs more time, it must tell you the reason and send a decision within 15 additional days. No further extension is allowed.
- Your insurance company must have a process for responding to emergency complaints (expedited review) more quickly.
- If your insurance company rejects your first appeal and your plan is through an employer, you may have the right to a second appeal.
- Your insurance company has seven days to acknowledge each appeal and 30 days to respond.
- If your insurance company rejects all appeals, you have the right to an independent external review to determine:
- Whether treatment is medically necessary.
- Whether treatment is experimental or investigational.
- Whether treatment is for continuity of care.
- Other "adverse benefit" issues such as the insurance company rescinded or ended your coverage.