Consumer health appeals and external review

Under Missouri law, you have the right to appeal the insurance company’s decision to deny your treatment. This is an opportunity for you or your provider to give additional information to your insurance company or clear up any miscommunications about your treatment.

Here is what you need to know:

• For group health plans, you have two chances to appeal the decision directly to the insurance company. These are called first- and second-level grievances or appeals. For individual plans you may only have one level of appeal; however, some individual plans allow two levels of appeal. You will need to refer to your policy to find out how many levels of appeal your plan allows.
• These appeals ensure a full, fair and impartial review of the company’s denial.
• There is an expedited appeals process for urgent medical matters.
• Your health plan is required to provide you with information on your rights to appeal and how to begin the process.
• DCI can assist you with information about the appeals process. 

Missouri law also provides for an external review of a medical claim when you and your insurance company still disagree on coverage of a treatment or medical service under your health plan. The department suggests you utilize all appeals and grievance options available through your health insurance carrier; however, you are not required to exhaust those options prior to requesting an external review.

Current Independent Review Organizations (IROs) under contract to perform external review for the department:

• CIMRO
  Contract Number CS220129003
• Maximus Federal Services
  Contract Number CS220129002
• Kansas Foundation for Medical Care, Inc.
  Contract Number CS220129001

Frequently asked questions about external review

What is external review? 

External review is an additional level of review or appeal that you can utilize to resolve disputes between you and your insurance company over treatment. In Missouri, the review is done by an external "Independent Review Organization," or IRO. 

That IRO assigns the cases to physicians who practice and are certified in the specialty involved with your condition or treatment. The IRO makes sure that the physician who reviews your file has no personal or professional conflicts with your insurance company. 

Is my medical situation eligible for an external review?

You can appeal if the company decides your treatment is not medically necessary, is experimental, is not as effective as other treatments or that you require a different or lesser level of care. 

DCI's Division of Consumer Affairs will review all external review requests and will notify both you and your insurance company if the claim or treatment is eligible for external review. 

How long after a denial must I file a request for external review?

Currently, there is no time limitation under Missouri law. The sooner you contact the Division, the sooner we can try to help you resolve the matter. 

Are all health plans covered under Missouri law – including self-insured employer group health plans?

No. To be eligible for external review through DCI, your health coverage must be through an insurance policy, not through a self-funded health plan sponsored by your employer. You can find out if your employer is self-funded by asking your Human Resources Department. 

What types of medical services can be referred for external review?

• Hospitalization
• Surgery
• Mental Health and Substance Abuse Treatment
• Physical Therapy
• Outpatient Services
• Pharmacy
• Cancer Treatments

What types of services cannot be referred for external review?

• Workers’ Compensation
• Automobile Medical Payment Claims
• Automobile Liability Medical or Personal Injury Claims
• Long-Term Care
• Disability Income

What is the fee for external review?

Currently, there is no charge to consumers seeking an external review under Missouri law. 

How do I request an external review?

Contact DCI. We will review the claim, contact the company for additional information, including a copy of all of documents in the company’s claim file. We will first review the matter to determine if there is a dispute that we can resolve. For instance, if the claim involves a violation of Missouri insurance law or a policy provision, we will work to resolve those issues instead of referring to the IRO.

If the claim is eligible for external review, we will notify both you and the insurance company. Both you and the insurance company will have 15 working days to provide any additional medical information that you wish to have reviewed and considered.   

I have an urgent medical situation.  Is there an expedited process for external review?

Yes. Contact DCI as soon as possible. Our IRO will provide a response within 72 hours of its receipt of all medical information about the claim or treatment.

Is external review a binding process?

Yes. Under current Missouri law, the result of the external review is binding upon both you and the insurance company, with some limited exceptions for judicial review. 

How long does the external review process take?

Once the IRO receives all information to be considered, it provides a response to us within 20 calendar days. Once that decision is made, you will be notified of the decision as soon as possible. The entire external process should take no longer than 45 calendar days, from the date the IRO receives all information to be considered to the notification of the outcome of the review.