Whom to contact:

New Hampshire Insurance Department

Who can appeal:

You or anyone you have given consent to represent you including your health care provider.

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational. The cost of the denied services is or is anticipated in a 12-month period to be equal to, or in excess of, $400.

When you can appeal:

You must file within 180 days of the date of the health carrier’s second- level denial. Some exceptions allow you to file earlier, such as if the health plan agrees to file earlier or if the health plan does not meet time requirements for decisions.

What to send:

1. Competed external appeal request form
2. Copy of letter denying service at final level
3. Evidence of insurance (e.g., photocopy of insurance card)
4. Copy of certificate of coverage or policy benefit booklet
5. Any medical records or other information you want the reviewer to consider

What you must pay:

No charge

What will happen:

1. Preliminary review by the Insurance Department within 7 days of receipt to determine if the request is complete and eligible for review.
2. If the request is not complete, you have 10 days to supply the information needed.
3. If the request is complete, the Insurance Department selects an independent review organization and notifies you and the health plan.
4. After the appeal is accepted, the insurer must provide all relevant information to you and the review organization within 10 days.
5. You then have 10 more days to submit new or additional information. You may in some circumstances be permitted to discuss the case with the reviewer by telephone conference.
6. The record of the case will be closed and no new information may be provided after the second 10-day window.

When you will get a decision:

20 days after the record of the case is closed

In urgent situations:

Expedited review is available if delay would seriously jeopardize your life, health, or ability to regain maximum function and must be completed within 72 hours.