Whom to contact:

Your health plan

Who can appeal:

You or your authorized representative

What you can appeal:

Denials, modifications, reductions, or terminations of either coverage or payment for health care services.

When you can appeal:

After you have exhausted your health plan’s internal grievance procedure and have received an unfavorable decision, or if your health plan has exceeded the timelines for the internal procedure without good cause.

What to send:

Oral or written request. Each carrier must provide a clear explanation of the process upon request, upon enrollment to new enrollees, and annually to enrollees.

What you must pay:

No charge

What will happen:

1. Your health plan will select a certified independent review organization from the Insurance Commissioner’s designated rotational registry.
2. Your health plan will provide the pertinent documentation to the review organization within 3 business days of receiving your request for review.
3. The review organization will make a decision.

When you will get a decision:

Either 15 days after the review organization receives all necessary information or 20 days after the request for review, whichever is earlier. (In exceptional circumstances, the review organization may be allowed 25 days after the request for review.)

In urgent situations:

If delay would seriously jeopardize your health or ability to regain maximum function, you should get a decision within either 72 hours after the review organization receives all necessary information or 8 days after the request for review, whichever is earlier.