Whom to contact:

Your health plan

Who can appeal:

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

What you can appeal:

Denials, reductions, or terminations of coverage for services the health plan determines are (a) not medically necessary, (b) experimental or investigational and the enrollee has a terminal condition, or (c) questions of contract coverage (these are reviewed by the Superintendent of Insurance.)

Unless your case qualifies for expedited review, your cost for the denied services must exceed $500. Questions of contract coverage and experimental/investigational reviews are not subject to the $500 certification.

When you can appeal:

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

What to send:

1. A written request for standard reviews, or a phone call or fax followed up by written confirmation for expedited reviews.
2. If review is based on medical necessity, you must submit a certification from your provider that the cost to you for these services will exceed $500 (if applicable).

What you must pay:

No charge

What will happen:

For appeal of denial based on medical necessity or because the service is considered experimental or investigational and the enrollee has a terminal illness, you need to contact your health plan, who will then contact the Superintendent.

1. The Superintendent will randomly assign two independent review organizations to your case.
2. Your health plan will choose one of the independent review organizations.
3. The review organization will evaluate the information submitted and make a decision based on safety, efficacy, appropriateness, and cost effectiveness.

For appeal of denial based on question of contract coverage, you need to contact the Superintendent.

1. The Superintendent will determine if your service is covered and notify your health plan. If the case involves medical issues that would cost you $500 or more, the Superintendent will notify your health plan to either cover the service or provide an external review. If the services would cost less than $500, the case does not qualify for external review and is outside the Department’s jurisdiction.

When you will get a decision:

The Independent Review Organization has 30 days to complete the review for a standard review and 7 days for an expedited review. There is no time frame in which the Superintendent must complete the review.

In urgent situations:

Expedited review is available if delay will place your health in serious jeopardy, seriously impair your body function, or cause serious dysfunction of any body part or organ. For expedited review, your provider must explain why your medical condition is eligible.  You will receive a decision within 7 days of filing for review.