Whom to contact:

Your health plan

Who can appeal:

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

What you can appeal:

Denials or limitations of coverage for health care services your health plan considers are not medically appropriate.

When you can appeal:

After completing all levels of your health plan’s internal appeal procedure, you must file within 30 days of receiving written notice of an adverse determination.

What to send:

A written request, including necessary information or documentation to support your request

What you must pay:

No charge

What will happen:

1. Your health plan will provide for selection of an external independent reviewer jointly by you, your provider, and the health plan.
2. Your health plan will provide all documentation to the reviewer.
3. The reviewer will make a decision within 5 days of receiving all information.

When you will get a decision:

In general, 35 days after your health plan receives the request for external review.

In urgent situations:

An expedited review is available if denial of the service could significantly increase the risk to your health; a decision will be made within 24 hours of receiving all necessary information.