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.
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