If the health plan is unresponsive to the appeal, does not meet legal time limits, or does not offer a resolution satisfactory to the patient, he can request assistance from the Department of Corporations, which regulates managed health care service plans. The department has a toll-free telephone line for patients to call for help. If the problem is within the jurisdiction of the department, they will send the patient a form called Request for Assistance. It is important for the patient to know that the Department of Corporations cannot intervene until the patient has gone through the appeal or grievance process set forth in the plan's Evidence of Coverage booklet. If the life or health of the patient would be jeopardized by delay, the department can take expedited action even if there has been no appeal directly to the plan.
Some plans require enrollees to submit to binding arbitration of grievances.
It is not necessary for the patient to complete that process before filing a Request for Assistance with the Department of Corporations. Ask whether you can appear in person to make your case and whether you can bring a lawyer, friend or doctor with you. Adhere to deadlines and insist that your plan do so. Insist that claim reviewers be expert and neutral. Know the basis of your claim, and ask for citations from the medical literature.