Filing a Complaint

Filing a Complaint for Denial of Coverage of Naturopathic Services

If you have been denied out-of-network coverage for a medically necessary service or procedure performed by your naturopathic doctor, please take the time to submit a complaint to the California Department of Insurance (DOI) or the California Department of Managed Health Care (DMHC) using the forms provided on their websites. This a crucial step towards getting NDs covered by California insurance plans!



Step-by-Step Instructions for Submitting a Complaint

Step 1: Contact your insurance company

Before filing your complaint, you must file a formal grievance in writing with your health plan (ie, Aetna/Blue Shield, etc.). Ensure that you have notified your insurance company about your request for coverage of the services you received from your naturopathic doctor.
 
  1. Submit a superbill to your insurance company (ask your doctor to provide you with a superbill for any visits)
  2. Follow-up with any additional information requested by the insurance company. Ask your doctor if they received any correspondence from your insurance company regarding your superbill.
  3. Call your insurance company in an effort to resolve the issue.
  4. If denied, file an appeal through your insurance company. It can take up to 45 business days to receive a response from your insurer.
    • You can use this template for an explanation of why you are appealing the decision.
  5. If your appeal is denied, file a complaint with the California Department of Managed Health Care (DMHC), for HMO or PPO plans, or the California Department of Insurance (DOI).

Step 2: File a Complaint with the DMHC or the DOI

If your insurance company refuses to cover your naturopathic doctor as an out-of-network provider even after you've formally sought resolution, you should file a complaint with the California Department of Managed Health Care (DMHC) or the California Department of Insurance (DOI).

Before beginning your submission, contact the Health Consumer Alliance at (888) 804-3536. They will need to enter your 5-digit zip code and you will be assisted by the agency in your area. Health Consumer Alliance advocates for consumers and assists patients in getting their denial escalated to a second-level review by either the Department of Managed Health Care (DMHC) or the California Department of Insurance. (Normally if the plan is a HMO or PPO, the review will be conducted by DMHC.)

To submit a complaint to the DMHC or DOI, you will need:
 
  1. Copy of the patient's (signed) Assignment of Benefits, if applicable 
  2. Copy of claim forms submitted to the insurance company
  3. Copies of all correspondence between the provider and the insurance company, including all related (Explanation of Benefits) EOBs
  4. Copy of the Dispute Resolution Process determination letter
  5. Copy of the patient's insurance identification card - both sides
  6. Copy of the provider's contract with the insurance company, if any
  7. A copy of the completed Health Care Provider Request for Assistance form (HPRFA): Downloadable version available here. You can also submit a complaint using the Online Request for Assistance.

Step 3: Notify your doctor and the CNDA about your complaint

Notify the CNDA and your doctor that you have filed a complaint with the Department of Insurance. This allows the CNDA to track how often coverage of ND services are being denied and which insurance companies are more likely to deny coverage. If at all possible, send a copy of all complaint-related documents to the CNDA.
 
  • Email Frances, CNDA Legislative Affairs Coordinator, to let her know of your claim at coordinator@calnd.org. Frances will follow up with a request for more information.

Step 4: Advocate for Insurance Coverage of Naturopathic Medical Services
 
  • Insurance companies will respond to consumer demand! Call your insurance company directly and request coverage of naturopathic medical services.
     
  • If you receive your health care plan through your employer, speak with your Human Resources representative and let them know that you would like naturopathic medicine covered by your health care plan. Print this letter and attach these informational documents to give to your human resources representative. They can forward it directly to your insurer and use it when negotiating next year’s benefits package.

Important Points to Know:
 
  • Most supplements are not covered under health insurance plans.
  • If you do not file a formal grievance with your insurer first, you have no way to escalate the issues with the oversight agencies. 
  • The Naturopathic Medicine Committee (ND state board) will work with the Health Consumer Alliance group to track upticks in complaints surrounding naturopathic service denials.
  • As long as the services provided by the practitioner are within the practitioner’s scope, there should not be any reason why the services should not be covered. 
 

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