Source: http://coveragerights.org/alaska/
Timestamp: 2018-10-22 03:15:36
Document Index: 13945067

Matched Legal Cases: ['§ 21', '§ 21', '§ 21', '§ 21', '§ 21', '§ 21']

Alaska — Coverage Rights
Request an expedited internal appeal, if applicable. Expedited internal appeals are available in emergency situations. Your situation is an emergency if waiting 18 days for the requested treatment would jeopardize your life or health.[2] Contact your insurer immediately and ask for instruction on how to request an expedited internal appeal if you believe your situation qualifies.
Your insurer should provide you a response within 18 business days after your appeal is received.[3] If you requested an expedited internal appeal, your insurer should provide you with a response within 72 hours of receiving your appeal.[4]
During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You are entitled to an external review if your insurer denied your coverage for one of the following reasons:
Your insurer determined that the treatment or service was not medically necessary or appropriate;
Your insurer determined that the treatment or service was investigational or experimental; or
Your insurer did not provide you with a decision on your internal appeal within18 hours for standard appeals or 72 hours for expedited appeals.[6]
You are entitled to expedited external review if:
Your medical situation is urgent and waiting 18 days for the requested treatment would jeopardize your life or ability to function; or
The appeal decision concerns an admission, availability of care, continued stay, or health care item or service for which you have received emergency services but have not been discharged from a facility.
You should submit your request for an external review to your health insurer.[7] Your health insurer will submit your request to a qualified external review agency for consideration.[8] You will have an opportunity to send any documentation that your insurance company does not already have, including, but not limited to, additional medical records, the opinion of your treating physician, and any peer-reviewed studies applicable to your situation.[9] The external appeal agency will consider the following in making a decision in your case:
Guidelines or standards used by the health insurer in making its original decision to deny services;
Any personal health and medical information related to the condition for which treatment or medication has been denied to you;
Your physician or health care provider’s opinion; and
Your health insurance policy.[10]
The external appeal agency may also consider the following in making its decision:
Medical studies related to your condition;
The results of professional consensus conferences;
Practice and treatment guidelines;
Government-issued coverage and treatment policies;
Generally accepted principles of medical practice;
Peer reviews conducted by your health insurer; and
The community standard of care.[11]
You must file your written request for an external review within 60 days from the date that your insurer sent you the final decision.
The external appeal agency should respond to you within 21 business days.[12] If you requested an expedited external review, then the agency should respond to your request within 72 hours after your request is received.[13]
If your insurer denies your coverage after the external review process, you can file a complaint with the Alaska Division of Insurance (“Division”).
The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
The complaint may be submitted online here, faxed to (907) 269-7910, or mailed to the following address:
Anchorage, AK 99501-3567[15]
Within two weeks of filing your complaint, the Division should send you a letter with a file number and the name of the specialist assigned to investigate your complaint. The specialist will then contact your health insurer and attempt to resolve the issue.[16]
You can contact the Alaska Division of Insurance, Consumer Services section at (800) 467-8785 (calling from within the state) or (907) 269-7900 (calling from outside the state). The Division is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.
[1] Appealing a Health Plan Decision: How to Appeal an Insurance Company Decision, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/.
[2] Alaska Stat. § 21.07.020(6) (2016).
[3] Alaska Stat. § 21.07.020(5)(A) (2016).
[4] Alaska Stat. § 21.07.020(6)(A) (2016).
[5] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 25, 2016).
[6] Alaska Stat. § 21.07.050 (h)(1).
[7] Alaska Stat. § 21.07.050 (2016).
[12] Alaska Stat. § 21.07.050 (2016).
[15] Consumer Complaint, State of Alaska Div. of Ins., https://sbs-ak.naic.org/Lion-Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanishVersion=N (last visited Nov. 25, 2016).