How to Request Out-of-Network Care and File a Grievance with Confidence
Navigating health insurance can feel overwhelming, especially when the care you need isn’t available in-network. But don’t worry—you’re not alone! Whether you're requesting out-of-network care or challenging a decision with a grievance, understanding the process can help you advocate for the best outcomes. Let’s break it down step by step so you can take charge of your healthcare needs.
Step 1: Request Out-of-Network Care
If the care you need isn’t available in-network, you can ask your health plan for permission to use an out-of-network provider. This is often approved when no in-network provider can meet your specific needs.
How to Get Started:
Call your health plan’s member services to ask about their out-of-network process.
Write a request letter explaining why in-network options aren’t working (we’ve got templates for you below!).
Include supporting documents, like recommendations from your doctor or an evaluation.
The more specific you are, the better your chances of approval!
Step 2: Request a Case Review
Sometimes, insurance plans deny out-of-network requests. If that happens, don’t give up—you can ask for a case review! This is your chance to provide more details or new evidence to show why the care you’re requesting is essential.
Pro Tips:
Be clear about why in-network options aren’t working.
Include new information, like unsuccessful attempts with in-network providers or updated recommendations from professionals.
Stay calm and confident—this step is part of the process, not the end of the road!
Step 3: File a Grievance with Your Health Plan
If the case review doesn’t go your way, it’s time to file a grievance. A grievance is simply a formal complaint to your health plan about their decision or how they’re handling your request.
What You Need to Know:
Find out how to file—most health plans let you submit grievances online, by mail, or over the phone.
Clearly explain why you’re filing the grievance. For example, “In-network options are not available for my needs, and I’ve been denied access to appropriate care.”
Health plans typically have 30 days to respond to standard grievances or 72 hours for urgent cases.
Source for Timeline: The 30-day response requirement comes from California Health & Safety Code § 1368, which mandates that health plans respond to grievances promptly. Urgent matters must be addressed within 72 hours.
Filing a grievance puts your concerns on the record and can open the door to a resolution.
Step 4: Escalate to a Regulatory Agency
If you’re not satisfied with your health plan’s response—or if they take too long—you can escalate the issue. This is where state regulatory agencies or independent reviews can step in.
How to Escalate:
Contact your state’s health care regulatory agency. If you’re in California, visit the Department of Managed Health Care (DMHC) for resources and guidance.
File a complaint with the DMHC using their online grievance system at File a Complaint.
Provide all relevant documents, including your grievance and any responses you’ve received.
If appropriate, request an Independent Medical Review (IMR), where neutral experts review your case and make a final decision.
This step ensures you’ve explored every option to get the care you need.
Don’t let confusing processes stop you from getting the care you need. Download our free templates today: HERE
