State guide
Missouri
Pick the kind of plan you have to see who to call first. Missouri can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Missouri usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Missouri Department of Commerce and Insurance (DCI), Division of Consumer Affairs. See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Missouri.
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Medicare
Missouri State Health Insurance Assistance Program (Missouri SHIP, formerly Missouri CLAIM) gives free counseling. Or call 1-800-MEDICARE.
The short version for Missouri
Missouri is unusual because you do not have to finish your insurer's internal appeals before asking the state for an external review, although the Department of Commerce and Insurance suggests using them. You start by contacting the Department's Division of Consumer Affairs, which first tries to resolve the dispute itself and then refers unresolved medical disputes to an independent review organization. The final decision is binding on both you and the insurer.
At a glance: independent review for plans Missouri regulates
- Main regulator
- Missouri Department of Commerce and Insurance (DCI), Division of Consumer Affairs · 800-726-7390 (Insurance Consumer Hotline, 8 a.m. to 5 p.m. weekdays)
- Independent review
- A state process (External review)
- Deadline to request it
- No deadline is stated on the Department's page or in the regulation reviewed; ask as soon as you can
- Cost
- No fee is mentioned on the Department's page or in the regulation reviewed
- Decision time
- The review organization gives its opinion within 20 calendar days of receiving the request (up to 5 more if extended) and the Director decides within 25 calendar days after that; the total cannot exceed 45 days; fast track: 72 hours
Who regulates health plans
- Missouri Department of Commerce and Insurance (DCI), Division of Consumer Affairs
Health insurance companies and policies subject to Missouri insurance law (individual plans and fully insured employer plans). It cannot act on plans not subject to Missouri insurance law or governed by other agencies.
Phone: 800-726-7390 (Insurance Consumer Hotline, 8 a.m. to 5 p.m. weekdays). File a complaint online
Independent (external) review
- Process
- A state process. Run by Missouri Department of Commerce and Insurance, which refers unresolved cases to a contracted independent review organization.
- Where you file
- regulator
- How
- Call the Insurance Consumer Hotline at 800-726-7390 or file a complaint with the Division of Consumer Affairs online, by fax (573-526-4898) or by mail (P.O. Box 690, Jefferson City, MO 65102-0690) and say you want an external review. The Division reviews the dispute and, if it stays unresolved, sends it to an independent review organization; you then have 15 working days to add information.
- Which denials qualify
- Disputes that are medical in nature: a difference of opinion between your treating health care professional and the insurer about medical necessity, appropriateness, health care setting, level of care or effectiveness of a service.
- Appeal to the plan first?
- No. The Department suggests using all of your insurer's appeal and grievance options, but says you are not required to exhaust them before requesting an external review.
Free help in Missouri
- Missouri Department of Commerce and Insurance, Division of Consumer Affairs (Insurance Consumer Hotline)
Explains the appeals process, requires the insurer to respond to your complaint, checks the response against Missouri law and your policy, and uses external review for medical disputes on state-regulated coverage.
Phone: 800-726-7390
Medicare and Medicaid in Missouri
- Medicare counseling
- Missouri State Health Insurance Assistance Program (Missouri SHIP, formerly Missouri CLAIM) · 800-390-3330 . Free help with Medicare appeals.
- Medicaid agency
- Missouri Department of Social Services, MO HealthNet Division (MO HealthNet)
- Fair hearing deadline
- 90 days from the date on your Action Notice; if you are in a MO HealthNet Managed Care health plan, 120 days from the date of the plan's Notice of Appeal Resolution. Your notice states the deadline that applies to you.
- Good to know
- Managed care members appeal to the health plan first (plan materials give 60 calendar days from the denial notice), then can ask for a state fair hearing. To keep benefits while the hearing is pending, ask within 10 days of the date on the notice. For help asking for a state fair hearing about a managed care decision, plan materials direct members to the MO HealthNet Division at 1-800-392-2161; for Family Support Division decisions call 855-373-4636.
State laws that can help
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External review. Grievances about adverse determinations that the Director cannot resolve must be referred to an independent review organization, and the resulting decision is binding on you and the insurer; you may file without exhausting the insurer's grievance process.
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Step therapy. A step therapy override must be granted if you already tried the required drugs under a current or previous plan and they were stopped for lack of effect or an adverse event, or if your provider attests the prescribed drug is necessary to save your life.
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Surprise billing. For unanticipated out-of-network care (emergency care from an out-of-network professional at an in-network facility), the professional must bill your insurer, and payment disputes go to arbitration between the provider and the insurer.
Sources and what we could not confirm
- External Review Process (Missouri Department of Insurance)
- Insurance Complaints (Missouri Department of Insurance)
- 20 CSR 100-5.020 Grievance Review Procedures (Cornell Legal Information Institute copy)
- Missouri SHIP
- Know Your Rights (Missouri Department of Social Services, Family Support Division)
- Hearings Information IM-4 (Missouri Department of Social Services)
- MO HealthNet (Missouri Medicaid) FAQs
- CMS: State External Appeals Review Processes
- CMS: Consumer Assistance Program
Not confirmed (8)
- The deadline to request independent review. neither the Department's page nor the regulation states a filing deadline; do not assume there is none
- The cost of independent review. no official statement found either way
- How long a standard independent review takes. timelines read from a copy of regulation 20 CSR 100-5.020 on a legal reference site, not from the Department's own page
- The independent review request form. there is no separate external review form; the request starts as a call or complaint to the Division of Consumer Affairs
- How to tell whether the state regulates your plan. the Department's complaint page has a 'health plans we do not regulate' section that was not captured
- Notes on Medicaid appeals. the 60-day plan appeal deadline and the 1-800-392-2161 number come from a MO HealthNet managed care plan's member document, not a state page
- Free consumer help programs. the federal directory lists Missouri as having a Consumer Assistance Program but no separate program page was found; the Department's consumer division is listed
- Published results of independent review. no officially published overturn rate found