Whom to contact:

Missouri Department of Insurance (MDI), Division of Consumer Affairs

Who can appeal:

You or your health plan

What you can appeal:

Denials of coverage for services the health plan determines do not meet requirements for medical necessity, appropriateness, health care setting, or level of care or effectiveness.

When you can appeal:

You may file after denial for coverage has been appealed and at any time through all levels of the health plan’s internal process.

What to send:

Written request

What you must pay:

No charge

What will happen:

• MDI checks that your request is appropriate for independent review.
• MDI requests you and your health plan to submit all relevant and pertinent information within 20 days (although you may take longer if necessary).
• MDI sends the entire request to the independent review organization.
• The review organization notifies the Director of MDI of its decision.
• The Director decides whether to agree or disagree (either entirely or in part) with the review organization’s decision and tells the health plan how to respond. The decision of the Director is binding on the health plan, unless appealed.

When you will get a decision:

The review organization will usually respond within 20 days after it receives all pertinent information.

In urgent situations:

No statutory procedures for an expedited review to the independent review organization. MDI can request the review organization to expedite as a courtesy.