Independent External Appeals

 

To qualify for an External Appeal:

The patient must be covered by a contract issued in Virginia by a Managed Care Health Insurance Plan (MCHIP). This includes HMOs and most PPOs. After exhausting all internal appeals, unless an expedited review has been requested, patients who have been denied coverage because their insurance plan determines the care was not medically necessary or involved experimental or investigative procedures, can file for an external review. All appeals must be filed within 30 days of the final decision of the patient's insurance plan to deny coverage. Patients must be covered by an eligible insurance plan, which disqualifies self-funded ERISA plans, Medicare, and Medicaid. Also, persons covered by federal employee health plans are not eligible to file appeals for external review with the Bureau. To be eligible for appeal, the patient's claim must exceed $300. There is a $50 filing fee with any appeal. This fee may be waived based on financial hardship.

How does an External Appeal work?

When the Bureau receives your appeal an initial review to verify your eligibility will be conducted. If you asked for an expedited appeal because you believe that you have an emergency medical condition a determination will be made as to whether an expedited review is warranted. If it is determined that you are not eligible or that an expedited appeal is not warranted, you will be so notified. If you are denied an expedited review you will be advised to use your plan's internal appeal process. If your appeal is accepted, the Bureau will ask an independent healthcare review organization that is not affiliated with your MCHIP to conduct a review of your appeal. You, your treating physician and your MCHIP will be asked to give the review organization all medical information pertinent to your appeal. The review organization will make a written recommendation to the Commissioner of Insurance who will review the recommendation to ensure that it is not arbitrary or capricious. The Commissioner will then issue a written ruling that will uphold, reverse, or modify the decision made by your plan. That ruling is binding and cannot be appealed.

External Appeal Forms

• Instructions for Completing the Appeal of Final Adverse Decision Form, Form 215A
• Important Terms and Definitions, Form 215B
• Appeal of Final Adverse Decision Form, Form 215C
• Authorization to Release Medical Information, Form 215D

External Appeal Brochure - What If Your Managed Care Company Says No?

contact text

Email: bureauofinsurance@scc.virginia.gov Phone: 804-371-9913