Whom to contact:

Your health plan

Who can appeal:

You or your provider (with written permission), or your authorized representative

If your provider files the grievance, he or she will be responsible for the cost of the review if the denial is upheld by the independent utilization review organization.

What you can appeal:

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

When you can appeal:

After denial for coverage has been appealed through the second level of the health plan’s internal process, you must appeal within 15 days from receipt of health plan’s decision.

What to send:

1. Enrollee’s name, address, and phone number
2. Name of health plan
3. Enrollee ID number
4. Copy of denial letter
5. Brief description of the problem
6. Any additional material that supports your position.

What you must pay:

Up to $25

What will happen:

1. The health plan will notify the state.
2. The state will assign your case to an independent utilization review organization.
3. The review organization will evaluate your case and provide written notice to you, the health plan, and the Department of Health.

When you will get a decision:

In about 60 days

In urgent situations:

If delay will jeopardize your life, health, or ability to regain maximum function, you should work with your plan to facilitate an expedited review, which will result in a 48-hour turn-around time.

Expedited reviews are also processed at the state level within two working days.