Whom to contact:

Your health plan

Who can appeal:

You or your authorized representative.  If you are unable to provide consent, a family member may be considered your authorized representative, or if a family member is not available, your health care provider may be considered your authorized representative.

What you can appeal:

Denial, reduction, or termination of payment for services that the health plan determines are not medically necessary or are experimental.   The cost to the health plan for the services in dispute must be at least $500.

When you can appeal:

In most cases, you may apply for external review after the adverse decision has been appealed through all levels of the health plan’s internal process within 60 days from receipt of the final adverse determination.

You may file for external review without having appealed through all levels of your health plan’s internal process if either your health plan agrees or if your health plan has not issued a written decision to your internal appeal within 30 days of filing a pre-service claim or within 60 days of filing a post-service claim.

What to send:

A request in writing (may be submitted by fax or email)

What you must pay:

$25 (This fee can be waived by the Commissioner if you show evidence of financial hardship.)

What will happen:

1. The health plan assigns your case to an Independent Review Organization (IRO).
2. The IRO conducts a preliminary review within 5 days to assure that your case meets requirements and includes all necessary information.
3. If your request is not complete, you, your provider, and your health plan will be notified about what information or materials are still needed.
4. You, your provider, or the health plan may provide additional documentation and information to the IRO within 7 business days of receiving notification by the IRO.
5. The reviewer makes a decision and notifies you, your provider, and the health plan.

When you will get a decision:

Within 45 calendar days after receiving your request for external review.

In urgent situations:

You can get an expedited review within 72 hours in three situations:

1. Delay will seriously jeopardize your life or health.
2. You have received emergency services but not yet been discharged from the facility.
3. The services in dispute are experimental or investigational and your provider certifies that treatment will be significantly less effective if not promptly started.