Whom to contact:

Office of General Counsel, Division of Health Planning

Who can appeal:

Enrollee or an eligible dependent of an enrollee of a managed care plan

What you can appeal:

Health plan denials of treatment for services that cost more than $500 and either appear to be covered services or are experimental treatments for patients with terminal conditions.

When you can appeal:

You must file after you have received a final notice of adverse outcome from your health plan after exhausting all levels of appeals within your health plan’s internal review process.

What to send:

1. A completed Request Form (located on the Division of Health website).
2. Total cost or estimate of procedure or service.
3. Copies of all denial letters from the provider.

What you must pay:

No charge

What will happen:

The Division of Health Planning will:

1. Notify you in writing that your request was received.
2. Determine if you are an eligible enrollee.
3. Randomly assign your case to an independent review organization and provide you with its name and address.

You or the health plan may be required to provide more information or documents within 5 days (although you may request an extension to 10 days).

The independent review organization will:

1. Review your case.
2. Made a determination in writing.

When you will get a decision:

15 days after the "additional information" deadline

In urgent situations:

If the standard time frame would jeopardize your health, life, or ability to regain maximum function, an expedited review may provide a decision with 72 hours after the reviewer receives all requested documents.