Whom to contact:

Your health plan

Who can appeal:

You or your health plan

What you can appeal:

1. Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational, or
2. Denials of coverage when medical judgment is needed to determine whether or not the service is a covered benefit under the plan, or
3. Denials of coverage based on failure to meet your health plan’s internal appeal deadlines.

When you can appeal:

You must make a "timely appeal" in writing.

What to send:

You are allowed to submit evidence related to the issues in dispute. The law requires the External Appeal Agency to consider:

1. The standards and guidelines used to make the decision,
2. Pertinent personal health or medical information,
3. Your provider’s opinion,
4. The group health insurance plan

The external appeal agency may also consider:

1. Reliable and valid studies,
2. Government conducted or financed professional conference results,
3. Government treatment and practice guidelines,
4. Government coverage and treatment policies,
5. Generally accepted principals of medical practice,
6. Expert opinions,
7. Peer reviews,
8. Community standard of care,
9. Anomalous utilization patterns.

What you must pay:

Charges incurred by you or your physician in support of the external appeal.

What will happen:

The External Appeal Agency will make a decision and supply the decision in writing to you and your health plan as soon as possible.

When you will get a decision:

No later than 21 working days after the appeal is filed.

In urgent situations:

An expedited review will be completed within 72 hours after the request for an external appeal.