Whom to contact:

Your health plan

Who can appeal:

You or your authorized representative

What you can appeal:

Denials of coverage for services costing more than $1,000 that the health plan determines are not medically necessary, medically appropriate, or medically effective.

When you can appeal:

After denial for coverage has been appealed through all levels of the health plan’s internal process, you must file within 30 days from receipt of the final adverse decision.

What to send:

A written request

What you must pay:

$50 (refunded if the external reviewer decides in your favor).

What will happen:

1. Your health plan will select an independent review organization.
2. The Department of Health will tell you which review organization was selected.
3. If you have reason to object to the selected reviewer, you may notify the Department within 3 days and the Department may allow you to select a different reviewer.
4. Within 5 days of final reviewer selection, you must provide:
   1. A written request for external review including the reasons why you are requesting the review,
   2. A copy of the decision to deny coverage from your health plan,
   3. A medical records release.
5. After receiving your information, the review organization will conduct a preliminary review to determine if your case is eligible for external review.
6. If your case is accepted for external review, your health plan will provide documentation within 5 business days of notification that the case has been accepted.
7. Within 5 days of receiving the health plan documentation, the review organization will request any additional information it needs from you. You will have 5 business days to provide the information or explain why it can’t be provided.
8. The review organization will decide your case.

When you will get a decision:

Within 30 days after acceptance of the request for external review and receipt of all documentation.

In urgent situations:

In an emergency that will jeopardize your life or health, an expedited review is available and you will receive a decision within 72 hours.