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Home / FAQ / Disponible en inglés: What are my rights when my health insurer or HMO will not pay for health care services? ES

Disponible en inglés: What are my rights when my health insurer or HMO will not pay for health care services? ES

Disponible en inglés:


If your health care provider tells you that a certain health care service is needed, but your health insurer or HMO disagrees, you have the right to appeal that decision and have it reviewed by an independent medical expert. A health care provider includes your doctor, a hospital or a person that is licensed to provide health care services, such as a psychologist, chiropractor, or physical therapist.

You may skip to Step 4 below and file a complaint directly with the Maryland Insurance Administration before receiving the health insurer or HMO’s decision if the health insurer or HMO waives its requirement that you first appeal to it, if the health insurer or HMO does not follow any part of its internal appeal process, or if you show a compelling reason, such as showing that a delay could result in your death, serious impairment to a bodily function, serious dysfunction of a bodily organ, or could cause you to be a threat to yourself or others.

Here’s how the process works:

  • Step 1: You will receive a letter from your health insurer or HMO notifying you of its decision.
  • Step 2: Follow the instructions in the first denial letter you receive from your health insurer or HMO to ask your health insurer or HMO to reconsider its decision. If you would like some help, contact the Health Education and Advocacy Unit in the Attorney General’s Office at 877-261-8807 for assistance. Your health care provider, or someone else you authorize to help you, can also do this for you.
  • Step 3: If your health insurer or HMO upholds its original decision to deny payment for the health care service, you may have your case reviewed by an independent medical expert, who will decide if the health care service your health care provider recommended is medically necessary. The Health Education and Advocacy Unit can help you with this too.
  • Step 4: If your policy allows you to file a complaint with the Maryland Insurance Administration (MIA), the MIA will send your case to an independent medical expert. The MIA will send you a copy of the opinion of the independent medical expert. If your policy does not allow you to file a complaint with the MIA, your health insurer or HMO will send your case to an independent medical expert. Your letter from your health insurer or HMO will tell you if you can file a complaint with the Maryland Insurance Administration. There are time limits for filing a complaint, so please carefully read your letter.
  • Step 5: If the independent medical expert finds the health care service recommended by your health care provider is medically necessary, the Insurance Commissioner, after considering all the facts of your case, may order your health insurer or HMO to pay for the health care service in accordance with your policy.

You have the right to appeal other coverage decisions made by your health insurer or HMO but those appeals may not necessarily be reviewed by an independent medical expert.


How to File a Complaint with the Maryland Insurance Administration:
Complaints must be received in writing and include a signed consent form.


Contact the MIA to learn how to submit a complaint:

Maryland Insurance Administration
Attn: Consumer Complaint Investigation Life and Health/Appeals and Grievance
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Telephone: 410-468-2000 or 800-492-6116
TTY: 1-800-735-2258
Fax: 410-468-2270 or 410-468-2260 (Life and Health/Appeals and Grievance)
Online at www.insurance.maryland.gov.


How to Contact the Health Education and Advocacy Unit:

Office of the Attorney General Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Telephone: 410-528-1840 or 877-261-8807
Fax: 410-576-6571
Online at www.oag.state.md.us/consumer/heau.htm