Source: http://coveragerights.org/missouri/
Timestamp: 2019-04-22 14:04:02+00:00

Document:
How do I request a grievance review?
If your insurer denies your claim, you can request a reconsideration of its decision. Your insurer should provide you with a reconsideration decision within one business day.
Review the determination letter. Your insurer should have sent you a determination letter telling you it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
Collect information. In addition to the determination letter, collect all documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms to file the grievance, call your insurer and request these documents.
Request an expedited review, if applicable. You can request an expedited review of your case if waiting 55 to 110 days for your requested treatment would seriously jeopardize your life, health, or ability to regain function. You can submit your request for expedited review by phone or in writing.
If you have a group health plan and your insurer denies your claim after the first level grievance review, you can request second level grievance review. Your insurer must notify you of the procedure to request a second level grievance review with its decision on the first level grievance. An advisory panel consisting of members who were not involved in the first level grievance will conduct the second level grievance.
If you have an individual plan, review your policy to determine whether you are limited to the first level of grievance or if you have the option to request a second level of grievance.
How long should the internal grievances process take?
A first level internal grievance should take no more than 55 days to complete. A second level grievance should also take no more than an additional 55 days to complete. An expedited grievance request should take no more than 72 hours from when the insurer receives your request.
You require a different or lesser level of care.
You can request an expedited external review if your medical situation is urgent and waiting the 45 days it would take to complete a standard external review would jeopardize your life or ability to function.
The Department will then contact your health insurer to obtain copies of all documents in the insurer’s claims file and determine whether your case is eligible for external review. Once the Department determines that your case is eligible for external review, a representative will contact both you and your health insurer, and you will have 15 business days to provide any additional medical information that you would like the external review organization to consider in its review.
The external review process should take no more than 45 calendar days from the date the external review organization receives your information. If you requested an expedited external review, the process should take no longer than 72 hours from when the external review organization receives all medical information related to your claim.
If your insurer still denies your coverage after the external review process, you can file a complaint with the Department.
Once the Department receives your complaint, it will send you written confirmation and the tracking number for your complaint. The Department will forward a copy of your complaint to your health insurer and request a response. Your insurer will have 20 days to respond to the complaint. If the Department determines that a law or regulation has been violated, the Department will direct the health insurer to either reprocess any claims or request other corrective action.
You can contact the Department at (800) 726-7390. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.
 Mo. Rev. Stat. § 376.1365 (2016).
 Mo. Rev. Stat. § 376.1382.1 (2016).
 Mo. Rev. Stat. § 376.1389 (2016).
 Mo. Rev. Stat. § 376.1382 (2016); External Review Process, Mo. Dept. of Ins., https://insurance.mo.gov/consumers/health/externalreviewprocess.php (last visited Nov. 27, 2016).
 Mo. Rev. Stat. § 376.1385 (2016).
 Mo. Rev. Stat. § 376.1382 (2016); External Review Process, External Review Process, Mo. Dept. of Ins., https://insurance.mo.gov/consumers/health/externalreviewprocess.php (last visited Nov. 27, 2016).
 Mo. Rev. Stat. § 376.1382 (2016). This figure is based on adding up the number of days required to complete each step of the internal grievance process.
 External Review Process, MO. Dept. of Ins., https://insurance.mo.gov/consumers/health/externalreviewprocess.php (last visited Nov. 26, 2016).
 Online Insurance Consumer Complaint Form, MO. Dept. of Ins., https://insurance.mo.gov/consumers/complaints/consumerComplaint.php (last visited Nov. 26, 2016).
 Insurance Complaints Consumer Hotline, MO. Dept. of Ins., https://insurance.mo.gov/consumers/complaints/index.php (last visited Nov. 26, 2016).
 Health Care Providers – Complaint Process, Claim Filing Procedures, MO. Dept. of Ins., https://insurance.mo.gov/consumers/health/providercomplaints.php (last visited Nov. 26, 2016).

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