Whom to contact:

Your health plan

Who can appeal:

You, your provider, or your authorized representative

What you can appeal:

Denials or limitations of coverage for services costing you at least $500 that the health plan determines are not medically necessary. 

When you can appeal:

You may appeal

1. within 60 days after receiving a final adverse determination from your health plan, or
2. if the MCO has not made a decision about your requested service within the required time period for internal review.

The MCO may also submit the dispute to review without requiring you to exhaust all levels of internal review.

What to send:

A written request for external review

What you must pay:

No charge

What will happen:

1. Within 5 days of receiving your request for appeal, the MCO will notify you (or your representative or physician), the agent who performed the utilization review, and the Office for Consumer Health Assistance.
2. The Office for Consumer Health Assistance will assign an external review organization (ERO) to your appeal.
3. After being notified about the ERO assignment, the MCO has 5 days to provide all documents about your appeal to the ERO.
4. After being notified about your appeal, the ERO has 5 days to review your request and materials and to request additional information from you, your physician, or the MCO.
5. Within 15 days of receiving the information it needs to review your appeal, the ERO will decide your appeal.
6. The ERO will notify you, your physician, your authorized representative (if any), and the MCO of its decision.

When you will get a decision:

Most appeals are resolved within 60 days.

In urgent situations:

If your physician provides evidence that a delay in treatment will be an imminent or serious threat to your health, you may request an expedited review.  In this situation, the MCO must deny or approve the expedited external review within 72 hours after receiving the documentation from your provider.  The ERO must complete its review within 2 working days after receiving the assignment (unless you and the MCO agree to a longer period) and notify your and the MCO of its decision by telephone within 1 working day after completing the review.  The ERO has 5 working days after completing its review to provide the written decision.