Whom to contact:

The Division of Health Care Administration of the Department of Banking, Insurance, Securities and Health Care Administration

Who can appeal:

You or a representative of your choice

What you can appeal:

Denials, reductions, or terminations of coverage for claims of at least $100:

1. For covered services the health plan determines are not medically necessary.
2. Limitations on selection of providers that are inconsistent with laws, regulations, or plan limits.
3. For services determined to be experimental or investigational, or an off-label use of a drug.
4. Medically-based determination of a pre-existing condition.

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 90 days from receipt of the written adverse determination.

What to send:

1. A completed request for appeal form.
2. The filing fee (check or money order) or request for waiver or reduction of fee.

What you must pay:

$25 (the fee is waived under certain conditions).

What will happen:

1. The Division will evaluate the request and determine whether or not it qualifies for external review within 5 days.
2. The Division will contact you regarding whether or not your request is accepted for review.
3. If your request is accepted for review, the Division assigns your case on a rotating basis to an independent review organization.
4. The Division will ask you and your health plan to send it the pertinent documentation within 10 days. Your health plan may request an extension of up to 10 days for good cause. You may request an extension for any reason.
5. The Division will send you and your health plan the documentation provided by the other party. You and your health plan have 3 days from receiving the information to send a response to the Division.
6. After the documentation and responses have been received, the Division will send all of the documentation to the independent review organization assigned to your case.
7. The review organization will evaluate the information. You may have a telephone conference with the review organization and the health plan if you requested this on your application.

When you will get a decision:

30 days from the review organization’s receipt of the appeal. The review organization may request an extension for circumstances beyond its control, including receipt of additional information after it has received the appeal.

In urgent situations:

There is an expedited process in emergency or urgent care situations. An expedited appeal will be immediately considered, documentation must be submitted to the Division, and a review organization assigned within 48 hours of acceptance. The review organization will respond within 5 days, unless it determines that your case is not urgent.