If you disagree with a decision made by your health plan, you have several options. Read below to find out how to appeal a decision, file a complaint, and ask for an external review of your case.
Step 1: Tell the insurance company you want to appeal its decision.
You or your doctor can appeal treatment decisions if you disagree with them. Follow the procedures in the notice you got telling you the company denied the treatment or service.
If your condition is life-threatening or your health plan stops covering a medication you’re already taking, skip to Step 2.
If your claim was denied because your company said it isn’t medically necessary, skip to Step 3. You don’t need to file a complaint with us because we don’t decide if a treatment or service is medically necessary. Instead, ask your company for an external review.
Step 2: File a complaint.
If you’re not happy with the outcome of your appeal, you can file a complaint. Learn how by going to our webpage, How to file a health insurance complaint.
Step 3: Ask for an external review.
If you're not happy with how the appeal turned out, you can ask for an external review. You can also ask for a review if your plan denied a service because it didn’t consider it medically necessary or because the service is experimental or investigational.
Someone who doesn’t work at the insurance company or for your provider (an independent reviewer) will decide if the insurance company must pay for the service. External reviews are free to you.
Who you ask for a review depends on what kind of health plan you have:
- Plans through your job with a school district; city, state, or county government; union; or church: Follow the process outlined in your employee's benefit booklet or ask the benefits coordinator at your job.
- For plans through your job with a large employer (more than 50 employees): Visit the U.S. Department of Labor’s website.
- Plans bought before March 23, 2010; stand-alone dental or vision plans; or disease-specific plans (like cancer only plans): Send a request form to us. Your insurance company sent you the form when it denied a service. For questions about the Texas independent review organization (IRO) process, call TDI's Managed Care Quality Assurance Office at 866-554-4926.
- Plans through the Marketplace (HealthCare.gov); CHIP; or your job with a small employer (fewer than 50 employees): Use the federal Health and Human Services (HHS) external review process. You have four months from the date your plan sent you the final decision to ask for an external review. Visit the HHS website or call 888-866-6205 for more information.
Not sure? If you’re not sure what type of plan you have, call us at 800-252-3439.
Step 4: Talk to an attorney about your legal options.
If you’re not satisfied with the outcome of your dispute, you may have the option to sue the insurance company. Use our Getting legal help page to learn about resources that might help.