Has Your Health Insurer Denied Payment for a Medical Service? You have a Right to Appeal
Alaska’s 80th Percentile Rule, a longstanding consumer protection in place since 2004, requires out-of-network health insurers to cover an amount equal to or greater than the 80th percentile of healthcare charges for a given geographic area. In simple terms, insurers must pay the going rate in the community.
If you feel your insurer improperly denied proper payment for your healthcare – leaving you with a large bill - the Alaska State Division of Insurance may be able to help make your insurer pay their fair share. You could be eligible for assistance through a State of Alaska Division of Insurance Appeals Consumer Complaint process.
Right to coverage: Insurance companies often deny payment for medical services and procedures for out-of-network services, leaving patients with big bills. However, under Alaska’s 80th Percentile Rule, your insurance provider is required to pay the 80th percentile of charges in your area. Under this rule, Alaskans are protected from surprise medical billing.
Right to appeal: While many providers utilize the 80th Percentile Rule on your behalf, often behind the scenes, it is the patient’s final responsibility to hold individual insurers accountable. Patients may file a Consumer Complaint with the Alaska Division of Insurance to appeal the insurance companies’ denial. The Division of Insurance has helped other Alaskans have their healthcare bills paid in full through application of this rule.
80th Percentile Rule Protects Patients: Thousands of Alaska patients each year benefit from the consumer protections of the 80th Percentile Rule. In fact, if you recently received care from an out-of-network provider, your medical services were likely covered under this rule. If you were left with an unexpectedly high medical bill by your insurer, you are entitled to protection and reimbursement of your costs. Even if you have had care in the past, and paid the bills yourself, you can still appeal an insurer’s denial of payment with the Division of Insurance.
Here’s How It Works:
If you received care from an out-of-network provider, and your insurance company denied payment, you have the right to dispute the decisions made by your insurer to deny coverage or payment for a medical service.
Use the following link to file a Consumer Complaint with the State of Alaska Division of Insurance, and read the Division of Insurance’s guidelines and advice available on the website.
Fill-out the necessary personal and insurance information; including “individual health" insurance” and “Claim Denial.”
In the details of complaint, outline your personal medical case, including primary health insurance and medical provider. Include the following language:
“My health insurer recently denied payment for my out-of-network medical care. However, under Alaska’s 80th Percentile Rule, my health insurance is required to reimburse my medical provider at the 80th percentile of charges in the area. Unfortunately, this did not occur and I was balanced billed for my medical procedure.”
Please note: The Alaska Division of Insurance recently abolished the consumer protection known as the 80th Percentile rule effective January 1, 2024. The appeals process outlined above for the 80th Percentile rule is only available until January 1, 2024.