What can I do if my health insurance denies my medical claim as being "not medically necessary"?
August 30, 2022
Your health treatment has been denied because your health insurer says it is not "necessary"?
It's not unusual for health insurers to deny coverage for procedures and medications which they deem "not medically necessary." Typically, this might start with a procedure which requires you to get advanced approval from the health insurance company. Your doctor has probably submitted a request that the procedure be approved and your insurer has said that they do not believe the procedure or course of treatment is medically necessary. At that point, you have to work through your own health insurer's internal appeals process.
Exhaust your internal appeals
The internal appeals may be a single step or may be multiple steps. Make sure you go through all levels of internal review, also known as "exhausting remedies." The appeal levels should be listed in your insurance contract or summary plan description. If you don't have a copy, make sure you request one from the insurer.
If you exhaust the appeals within your health insurance company, and you have a certain type of health plan coverage, you can request an "External review" through the NC Department of Insurance. External review is available for most health insurers that make coverage decisions based on medical necessity. Other types of denial decisions are not eligible for external review.
Medical necessity decisions made by North Carolina State Health Plan are also subject to external review.
External review through DOI not available on certain plans
The NC Department of Insurance says that "North Carolina's state external review does not apply to self-funded employer health plans. (These are health plans for which an employer sets aside his own funds to pay for health claims rather than purchasing insurance, and are often "administered" by health insurance companies.) External review also does not apply to Medicare or Medicaid and is not available for certain types of insurance, including: dental, vision, Medicare supplement, long-term care, specified disease, workers compensation, credit, or disability income, or to medical payments under homeowners or auto insurance."
If your plan allows for external review visit the NC Department of Insurance Website to request an External Review
The North Carolina Department of Insurance runs the external reviews. They are available whether you have already received a service and coverage for it has been denied or you have requested and been denied coverage for a service that you have not yet received.
Most people will qualify for a standard external review, which results in a decision within 45 days of submitting a request for review. An expedited external review, under which a decision is made within three days of submitting a request, is available in cases where the time involved in obtaining a final decision can have an impact on a person's health.
Yes, external review is free
There are no charges for the external review process. Hopefully, your medical providers will not charge you to fill in the forms for you saying the care was/is medically necessary. Ask them when you send them the forms. Usually they won't, because if you win the external review, then the health insurance company must pay for the procedure.
You should request your external review within 90 days of the denial of service.
Here is the link to review the process at the NC Department of Insurance: