Whom to contact:

Director of the District of Columbia Department of Health

Who can appeal:

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

What you can appeal:

Denial, reduction, limitation, termination, or other delay of covered health care services.

When you can appeal:

After denial for coverage has been appealed through the health plan’s formal internal process, you must file within 30 days from receipt of the written decision of the health plan. If the health plan fails to meet the deadlines for completing a formal internal appeal, the member may begin the external process without waiting for the health plan’s decision.

What to send:

1. Written request for appeal
2. Completed medical record consent form
3. Final decision of health plan

What you must pay:

No charge

What will happen:

The Director will:

1. Evaluate the appeal for processing (is the complainant a member, are the requested services covered benefits, is all information available, etc.)
2. Notify you whether the appeal is eligible for processing
3. If acceptable, assign the appeal on a rotating basis to an independent review organization.

The independent review organization will:

• Conduct a full review by at least 2 physicians.

Either you or a health plan representative may request to appear in person at a hearing by the review organization.

When you will get a decision:

Within 30 business days from the time the independent review organization is assigned.

In urgent situations:

You may be able to start the appeals process before completing the informal and formal urgent appeals in cases of emergency or urgent care. An expedited appeal will be completed within 72 hours from the time the independent review organization is assigned.