Whom to contact:

Your health plan

Who can appeal:

You, your provider (with consent), or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental.

When you can appeal:

After denial for coverage has been appealed through all levels of the health plan’s internal process, you must appeal within 60 days from receipt of the final adverse determination.

What to send:

A completed request form

What you must pay:

No charge

What will happen:

1. Health plan notifies the insurance department by fax that you have requested an external review.
2. The insurance department assigns an independent external reviewer.
3. The health plan sends all relevant information to the reviewer. The reviewer may request additional information from you, your doctor, or your health plan.
4. The reviewer makes a decision and notifies you, your health plan, and the department of insurance.

When you will get a decision:

Within 30 working days (the deadline may be extended 10 additional working days if additional information needs to be considered).

In urgent situations:

If a delay will jeopardize your health (you must have your doctor’s certification), you can get an expedited review within 7 days. This can be extended 5 more days if the reviewer needs more time.