Who to contact:

Subscriber Assistance Program (SAP)

Who can appeal:

You, your provider (on your behalf), or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational, non-authorization or denial of services you believe are covered by the plan, out of network requests.

When you can appeal:

You must file only after completing all levels of the health plan’s internal grievance procedure. You must file within 365 days of receiving the notice of final denial.

What to send:

A completed "Request for Review and Release Form"

What you must pay:

No charge

What will happen:

1. You send the release form and supporting information.
2. The health plan submits pertinent information.
3. The SAP analyst determines whether the case is one over which the program has jurisdiction.
4. The SAP analyst prepares the information for a hearing.
5. A hearing is scheduled.
6. You and your health plan will participate by telephone conferencing with the SAP panel. You and your health plan will each have 15 minutes to present your case, and 5 minutes of rebuttal, if necessary.
7. The SAP panel will evaluate the case and prepare a written recommendation within 15 working days, unless more time is needed to gather necessary information requested by the panel.
8. You and your health plan have 10 days after receiving the recommendation to submit written objections.
9. The Agency or the Department of Finance, Office of Insurance Regulation, depending upon which department has jurisdiction in the case, will make a final determination. The final Proposed Order will be sent to you.
10. The health plan has 30 days to comply if the final order is in your favor.

When you will get a decision:

Within 165 days

In urgent situations:

An expedited review is available for cases in which there is a serious threat to continued health. An expedited review is scheduled for hearing within 45 days and resolved within 65 days. If there is an impending threat of death, an emergency case is heard within 24 hours.