Whom to contact:

Your health plan

Who can appeal:

You or your authorized representative

What you can appeal:

Denials or limitations of coverage for services the health plan determines are not appropriate, medically necessary, or are experimental or investigational.

When you can appeal:

After denial for coverage has been appealed through all levels of the health plan’s internal process, you must file within 45 days from receipt of the final adverse determination.

What to send:

A written request for external review

What you must pay:

The health plan may charge you up to $25 towards the cost of the review.

What will happen:

1. The plan selects an independent review organization for your case on a rotating basis and sends pertinent information.
2. The reviewer may ask for additional information.
3. The reviewer will notify you and your health plan of the decision.

When you will get a decision:

Within 15 business days of filing for review.  The reviewer has an additional 72 hours to notify you of this decision.

In urgent situations:

If a delay will seriously jeopardize your health, life, or ability to regain maximum function, an expedited review can be completed within 72 hours of filing.  The reviewer has an additional 24 hours to notify you of this decision.