Know your rights when your health insurer1 will not pay for health care services
If your health care provider2 tells you that a certain health care service is needed, but your health insurer disagrees, you have the right to appeal that decision and have it reviewed by an independent medical expert also known as an independent review organization (IRO)3.
Here’s how the process works:
Step 1: You will receive a letter from your health insurer notifying you of its decision.
Step 2: Follow the instructions in the first denial letter you receive from your health insurer or HMO to ask your health insurer to reconsider its decision. If you would like some help, contact the Health Education and Advocacy Unit in the Attorney General’s Office at 877-261-8807 for assistance. Your health care provider, or someone else you authorize to help you, can also do this for you.
Step 3: If your health insurer upholds its original decision to deny payment for the health care service, you may have your case reviewed by an independent medical expert, who will decide if the health care service your health care provider recommended is medically necessary. The Health Education and Advocacy Unit can help you with this too.
Step 4: If your policy allows you to file a complaint with the Maryland Insurance Administration (MIA), the MIA will send your case to an independent medical expert. The MIA will send you a copy of the opinion of the independent medical expert. If your policy does not allow you to file a complaint with the MIA, your health insurer will send your case to an independent medical expert. Your letter from your health insurer will tell you if you can file a complaint with the Maryland Insurance Administration. There are time limits for filing a complaint, so please carefully read your letter.
You may skip to Step 4 and file a complaint directly with the Maryland Insurance Administration before receiving the health insurer’s decision if:
- the health insurer waives its requirement that you first appeal to it, or
- if the health insurer does not follow any part of its internal appeal process, or
- if you show a compelling reason, such as showing that a delay could result in your death, serious impairment to a bodily function, serious dysfunction of a bodily organ, or could cause you to be a threat to yourself or others, or could cause you to continue to experience severe withdrawal symptoms.
You are considered to be a danger to yourself or others if you are unable to function in activities of daily living or care for yourself without imminent danger or consequences.
Step 5: If the independent medical expert finds the health care service recommended by your health care provider is medically necessary, the Insurance Commissioner, after considering all the facts of your case, may order your health insurer or HMO to pay for the health care service in accordance with your policy.
You have the right to appeal other coverage decisions made by your health insurer or HMO but those appeals may not necessarily be reviewed by an independent medical expert.
How to File a Complaint with the Maryland Insurance Administration:
Complaints must be received in writing and include a signed consent form.
Contact the MIA to learn how to submit a complaint at:
Maryland Insurance Administration
Attn: Consumer Complaint Investigation
Life and Health/Appeals and Grievance
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Telephone: 410-468-2000 or 800-492-6116 TTY: 1-800-735-2258
Fax: 410-468-2270 or 410-468-2260 (Life and Health/Appeals and Grievance)
Or visit our website.
How to Contact the Health Education and Advocacy Unit:
Office of the Attorney General
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Telephone: 410-528-1840 or 877-261-8807 Fax: 410-576-6571
Or visit their website.
1 Health insurer includes health insurance companies, HMOs and non-profit health insurance plans.
2 A health care provider includes your doctor, a hospital or a person that is licensed to provide health care services, such as a psychologist, chiropractor, or physical therapist.
3 Under Maryland law, providers are permitted to appeal the decision on behalf of the patient if the patient provides consent.
Additional Resources:
