Whom to contact:

Your health plan.

Who can appeal:

You or your authorized representative

What you can appeal:

Denied health services that are not considered medically necessary, effective, appropriate, at the appropriate level of care, or provided in the appropriate setting. For conditions that are life threatening or seriously disabling, services considered experimental or investigational may be appealed. The amount payable for covered benefits must be at least $500.

When you can appeal:

For a standard review, you must apply within 60 days after receiving notice that your request for services has been denied. You must apply within 15 days for an expedited review.

What to send:

Request an external review in writing.

What you must pay:

No charge

What will happen:

Within 5 business days of receiving your request for external review, your health plan will either:

1. Assign your case to an independent review organization and send documentation to the review organization, or
2. Notify you in writing why your request does not meet the requirements for external review.

If your health plan does not send the documentation, the review organization may terminate the review and reverse the adverse determination or final adverse termination.

Within 5 business days of receiving the request for external review, the review organization will evaluate whether or not the necessary information has been received and notify you if additional information is needed. You must also submit additional information and documentation to support your case within 7 business days after receiving this notification.

In general, the review organization will evaluate the documentation and make a decision. If your appeal concerns an experimental or investigational treatment, the review organization will select a review panel and the reviewers will submit written opinions. The review organization will then make a decision to uphold or reverse your health plan’s determination. Decisions regarding denials of experimental or investigational treatments must be based on the recommendation made by the majority of the panelists.

When you will get a decision:

Within 45 days after the review organization receives the request from your health plan.

In urgent situations:

An expedited review is available if the patient has a serious medical condition or is requesting continued care after receiving emergency treatment. You must apply for expedited review within 15 days of receiving notice that your request for services has been denied. A decision will be made no more than 3 business days after the request was received by the health plan.