Whom to contact:

Virginia Bureau of Insurance (BOI)

Who can appeal:

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

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or involve experimental or investigative procedures. The cost of the denied services must exceed $300.

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 of the final decision to deny coverage.

What to send:

A completed appeal form (you can call the ombudsman for help)

What you must pay:

$50 (the fee may be waived for financial hardship and is refunded if you are not eligible)

What will happen:

1. The BOI will review your appeal to verify eligibility.
2. The BOI will select an independent healthcare review organization.
3. You, your physician, and the health plan will be asked to provide pertinent information within 20 working days.
4. The review organization will recommend a decision.
5. The Commissioner of Insurance will review the recommendation to assure that it is not arbitrary or capricious.

When you will get a decision:

30 working days after the review organization receives all pertinent information.

In urgent situations:

An expedited appeal is available in an emergency or if required by an emergency medical condition. The BOI will decide if your situation warrants an expedited appeal, and, if so, the review organization will decide your case within 5 working days after the review organization receives all pertinent information.