Whom to contact:

Connecticut Insurance Department

Who can appeal:

You, your provider (with your written consent), or your legal representative

What you can appeal:

Denials of coverage for services covered in your contract that your health plan determines are not medically necessary.  An appeal may be filed before, during, or after the service in dispute is provided.

When you can appeal:

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

What to send:

1. A completed "Request for External Appeal" form (available from the Insurance Dept).
2. Evidence of enrollment (such as a photocopy of your insurance card)
3. Copies of all pertinent correspondence
4. Copy of letter saying all internal appeals have been exhausted
5. Copy of certificate of coverage
6. Filing fee

What you must pay:

$25 (the fee is waived under certain conditions)

What will happen:

1. The Insurance Department will assign the appeal to an external review agent.
2. The external review agent will conduct a preliminary review to determine if the request is eligible for full review.
3. If the request is eligible, the external review agent will notify you, or your provider, and the plan of the opportunity to submit additional information within 5 business days. The external review agent will complete a full review and notify the Insurance Dept. of its decision.
4. The Insurance Dept. will notify you, your doctor, the plan, and the utilization review company.

When you will get a decision:

Preliminary review: A decision is provided to the Insurance Commissioner 5 business days after receipt of appeal.  The Insurance Commissioner reviews the decision and notifies all parties.

Full review: A decision is provided to the Insurance Commissioner 30 business days after completion of the preliminary review.  The Insurance Commissioner reviews the decision and notifies all parties.

In urgent situations:

No expedited external appeal process