Whom to contact:

Your health plan

Who can appeal:

You or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary, appropriate, or effective, services that are not provided in the required health care setting, or services that are experimental. The amount in dispute must exceed $256.

When you can appeal:

After denial for coverage has been appealed through the health plan’s internal process, you must file within 4 months from receipt of the final adverse determination or experimental treatment determination.

What to send:

1. Written request
2. The name of the review organization you want to review your case.

What you must pay:

$25 (if the review organization rules in your favor, even in part, your payment will be refunded)

What will happen:

1. Your health plan must submit all pertinent documents to the independent review organization within 5 business days of receiving your request.
2. The independent review organization will request any additional information it needs within 5 business days of receiving the initial documentation from your health plan.
3. Your health plan will send any additional information within 5 days of receiving the request for additional information.
4. You or your health plan may also submit additional medical or scientific evidence to each other and the review organization.

When you will get a decision:

Within 30 business days after the last of the data request time limits

In urgent situations:

If the independent review organization determines that the required time limits would jeopardize your life, health, or ability to regain maximum function, an expedited review is available. Information will be submitted by your health plan within 1 day, additional information will be requested within 2 days and then submitted within 2 days, and the review organization will make a decision within 72 hours after the last of the data request time limits.