Virginia: Bureau of Insurance's Ombudsman FAQs Page

MCHIPs vs. Traditional Health Insurance Plans
• Do I have an MCHIP?

Appeal Options Available to You

MCHIP Appeals Systems
• Explanation
• Does your office submit the appeal to my MCHIP for me or on my behalf?
• How do I submit an appeal to my MCHIP?
• I’ve seen that there is an Inquiry Form on your website that needs to be completed, signed and returned to you. At what point do I do this?
• I have seen information at other state’s websites about complaint ratios for MCHIPs licensed in that state. Do you publish MCHIP complaint ratios?

Expedited Appeals
• Explanation
• Does my expedited appeal have to be in writing?
• What if my expedited appeal is reviewed and denied?
• What if my MCHIP does not think my appeal is an urgent matter warranting an expedited appeal, and they decline to review my appeal as expedited?

External Appeals
• Explanation
• My MCHIP denied authorization for a procedure. My insurance contract does state that the procedure is not covered, but my doctor said it is medically necessary. Why didn’t I receive any information about the external appeals process?
• What happens if the denial is upheld on external appeal?

• Do I have an MCHIP?

There are basically two types of health insurance – traditional health insurance coverage (sometimes referred to as “indemnity” coverage), and managed care health insurance plans (MCHIPs). In general, MCHIPs encompass health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point-of-service (POS) plans. MCHIPs can provide health, dental and vision services coverage. If you have an MCHIP, you will normally receive a better benefit if you go to a participating (or In-Network) provider, rather than a non-participating (or Out-of-Network) provider. You may be required to choose a primary care physician (PCP), and you may need to get a referral to see any provider other than your PCP. Generally, you pay a deductible, copayment and/or coinsurance and the provider files the claims for you.
With a traditional health insurance plan, you are able to visit any health care provider you wish with few restrictions or benefit payment differentials. You might be required to pay for your services, and then file your own claims with your insurance company. The Office of the Managed Care Ombudsman cannot assist persons covered under traditional health insurance plans. If you are covered under a traditional health insurance plan and need assistance from the Bureau of Insurance, please contact the Life and Health Consumer Services Section. [TOP]

MCHIP Appeals Systems

• Explanation

All MCHIPs that are licensed in Virginia must submit their complaint and appeals system to the Virginia State Corporation Commission, Bureau of Insurance, as well as to the Virginia Department of Health, Center for Quality Health Care Services and Consumer Protection for approval. These systems are reviewed for compliance with Virginia law. At a minimum, MCHIP complaint systems must provide for one level of appeal. If the service or benefit being appealed is a determination of medical necessity, then the appeal is required to be reviewed by a health care provider who (i) is in a similar specialty as the treating provider, (ii) is neither a director nor an employee of the utilization review entity, and (iii) was not involved in the previous decision. This provider will then make his/her recommendation to the utilization review entity. Some MCHIPs allow the appellant to participate in an appeals committee hearing. You should receive a final decision to your written appeal within 60 days. Our office is familiar with the manner in which many MCHIPs operate their appeals process. If your MCHIP’s appeal process is unclear to you, we encourage you to contact our office for assistance. [TOP]

• Does your office submit the appeal to my MCHIP for me or on my behalf?

No. You, your health care provider or someone you have appointed to act on your behalf must submit your appeal. Our office can give you advice on making your appeal, and explain the process. In order to formally assist you in the appeal process, including contacting your MCHIP to discuss your case, we must receive a signed and completed Inquiry Form. [TOP]

• How do I submit an appeal to my MCHIP?

The Office of the Managed Care Ombudsman has developed informational material to help you with your appeal. Click here to view the items available at our website to provide you assistance. [TOP]

	Ombudsman FAQs What is a Managed Care Health Insurance Plan (MCHIP)? MCHIPs vs. Traditional Health Insurance Plans • *Do I have an MCHIP?* Appeal Options Available to You MCHIP Appeals Systems • Explanation • Does your office submit the appeal to my MCHIP for me or on my behalf? • How do I submit an appeal to my MCHIP? • I’ve seen that there is an Inquiry Form on your website that needs to be completed, signed and returned to you. At what point do I do this? • I have seen information at other state’s websites about complaint ratios for MCHIPs licensed in that state. Do you publish MCHIP complaint ratios? Expedited Appeals • Explanation • Does my expedited appeal have to be in writing? • What if my expedited appeal is reviewed and denied? • What if my MCHIP does not think my appeal is an urgent matter warranting an expedited appeal, and they decline to review my appeal as expedited? External Appeals • Explanation • My MCHIP denied authorization for a procedure. My insurance contract does state that the procedure is not covered, but my doctor said it is medically necessary. Why didn’t I receive any information about the external appeals process? • What happens if the denial is upheld on external appeal? • *Do I have an MCHIP?* There are basically two types of health insurance – traditional health insurance coverage (sometimes referred to as “indemnity” coverage), and managed care health insurance plans (MCHIPs). In general, MCHIPs encompass health maintenance organizations (HMOs), preferred provider organizations (PPOs) and point-of-service (POS) plans. MCHIPs can provide health, dental and vision services coverage. If you have an MCHIP, you will normally receive a better benefit if you go to a participating (or In-Network) provider, rather than a non-participating (or Out-of-Network) provider. You may be required to choose a primary care physician (PCP), and you may need to get a referral to see any provider other than your PCP. Generally, you pay a deductible, copayment and/or coinsurance and the provider files the claims for you. With a traditional health insurance plan, you are able to visit any health care provider you wish with few restrictions or benefit payment differentials. You might be required to pay for your services, and then file your own claims with your insurance company. The Office of the Managed Care Ombudsman cannot assist persons covered under traditional health insurance plans. If you are covered under a traditional health insurance plan and need assistance from the Bureau of Insurance, please contact the Life and Health Consumer Services Section. [TOP] MCHIP Appeals Systems • Explanation All MCHIPs that are licensed in Virginia must submit their complaint and appeals system to the Virginia State Corporation Commission, Bureau of Insurance, as well as to the Virginia Department of Health, Center for Quality Health Care Services and Consumer Protection for approval. These systems are reviewed for compliance with Virginia law. At a minimum, MCHIP complaint systems must provide for one level of appeal. If the service or benefit being appealed is a determination of medical necessity, then the appeal is required to be reviewed by a health care provider who (i) is in a similar specialty as the treating provider, (ii) is neither a director nor an employee of the utilization review entity, and (iii) was not involved in the previous decision. This provider will then make his/her recommendation to the utilization review entity. Some MCHIPs allow the appellant to participate in an appeals committee hearing. You should receive a final decision to your written appeal within 60 days. Our office is familiar with the manner in which many MCHIPs operate their appeals process. If your MCHIP’s appeal process is unclear to you, we encourage you to contact our office for assistance. [TOP] • Does your office submit the appeal to my MCHIP for me or on my behalf? No. You, your health care provider or someone you have appointed to act on your behalf must submit your appeal. Our office can give you advice on making your appeal, and explain the process. In order to formally assist you in the appeal process, including contacting your MCHIP to discuss your case, we must receive a signed and completed Inquiry Form. [TOP] *• How do I submit an appeal to my MCHIP?* The Office of the Managed Care Ombudsman has developed informational material to help you with your appeal. Click here to view the items available at our website to provide you assistance. [TOP] *I’ve seen that there is an Inquiry Form on your website that needs to be completed, signed and returned to you. At what point do I do this?* If possible, it would be best to contact our office first. By contacting our office, you will find out if it is necessary for you to complete the Inquiry Form. The form might not be needed if you have a question or a simple matter to which we can advise you over the phone. Additionally, we may need to refer you to another office for assistance. If you require our office’s formal assistance (where we will need to discuss your case with your MCHIP), you must complete, sign and return the Inquiry Form to us before we can assist you. You can obtain the form either by sending us a copy of the appeal letter you sent to your MCHIP and we will send you an Inquiry Form, by downloading the form from our website, or by contacting our office to have the form mailed or faxed to you. When you return the completed and signed Inquiry Form, please include the denial letter(s) from your MCHIP and your letter of appeal (if not already received by our office). [TOP] I have seen information at other state’s websites about complaint ratios for MCHIPs licensed in that state. Do you publish MCHIP complaint ratios? We do not post complaint ratios or percentages on the web site as some states do. We do, however, gather and review this information internally on an annual basis. We have found that in most cases the volume of complaints to enrollees is so small that reporting these figures could lack significance. There has basically been no change in this pattern since we began our review of MCHIP complaint systems. We feel that a more important measure to research is how responsive an MCHIP is to addressing the complaints it does have and keeping the covered person informed during the appeals process. If you are considering joining an MCHIP and are curious about the manner in which they handle their complaints and appeals you can contact our office, we can give you information on how the MCHIP’s complaint and appeals process operates. [TOP] Expedited Appeals *Explanation* You are entitled to an expedited appeals process through your MCHIP if your doctor believes that the delay caused by appealing through your MCHIP’s standard appeals process would be detrimental to your health or when your appeal relates to a prescription to alleviate cancer pain. MCHIPs are not required to have an outside provider review your expedited appeal. MCHIP decisions on expedited appeal must be made within one business day of their receipt of all information, or no longer than 24 hours when the decision relates to a prescription for alleviating cancer pain. [TOP] Does my expedited appeal have to be in writing? No. Your physician must be allowed to appeal immediately, by telephone, with another physician at your MCHIP. [TOP] • What if my expedited appeal is reviewed and denied? Your MCHIP must immediately inform the appellant of the final adverse decision via telephone, fax or email. At the same time the appellant must be notified that, if otherwise eligible, he or she has the right to appeal the decision to the Bureau of Insurance through the external appeal process. The notification must include the forms required for external appeal. The external appeal, if accepted by the Bureau of Insurance will be reviewed on an expedited basis. [TOP] • What if my MCHIP does not think my appeal is an urgent matter warranting an expedited appeal, and they decline to review my appeal as expedited? If your health care provider requested your expedited appeal on the basis that the regular appeals process would delay the rendering of care in a manner that would be detrimental to your health or life, and your MCHIP refused to review the request as expedited, this determination by the MCHIP is considered to be a final adverse decision. Thus, your MCHIP must immediately inform the appellant of this decision and the right to request an expedited external appeal from the Bureau of Insurance. This notification must be followed within 24 hours with a written notice providing the forms required to be filed for external appeal. If the Bureau of Insurance declines to review your appeal as expedited, you will be notified that you may request an appeal through your MCHIP’s standard appeal process. [TOP] External Appeals • Explanation If you receive a final adverse utilization review decision by your MCHIP, or if your MCHIP issues a final adverse decision on the basis that a service or procedure you requested is experimental or investigational , you should receive a letter from your MCHIP informing you about the external appeals process administered through the Bureau of Insurance, as long as you qualify otherwise. Forms for filing an external appeal should be attached to this letter if you are eligible. To be otherwise eligible for the external appeal process administered by the Bureau of Insurance (i) you must have completed your MCHIP’s internal appeals process, (ii) your MCHIP coverage must be fully-insured under a policy issued in Virginia, and (iii) the cost to you if the coverage remains denied must be greater than $300. You also may be eligible for external appeal if your MCHIP denies your expedited appeal or refuses to review a physician-requested appeal as expedited, and you meet the qualifications specified in (ii) and (iii). The forms for filing the external appeal must be filed with the Bureau of Insurance within 30 days of the date of the final adverse decision letter. The forms must be filed either with the $50 refundable filing fee, or with a request to waive the fee for good cause shown. [TOP] My MCHIP denied authorization for a procedure. My insurance contract does state that the procedure is not covered, but my doctor said it is medically necessary. Why didn’t I receive any information about the external appeals process? The external appeals process only pertains to utilization review decisions reviewing the necessity, appropriateness and efficiency of health care services. The external appeals process does not pertain to the denial of benefits which are explicitly excluded under the insurance contract. An exception to this is a denial on the basis that the services are experimental/investigational. Even though most MCHIPs specifically exclude coverage for services that are experimental/investigational, a denial for this reason is eligible for external appeal providing that the member otherwise qualifies. [TOP] *What happens if the denial is upheld on external appeal?* The reviewing entity supplies the reasons and rationale for its recommendation to the Commissioner of Insurance, or his designee. The Commissioner or designee reviews the recommendation to ensure that it is not arbitrary or capricious. The Commissioner or designee then issues a written ruling which either upholds, reverses or modifies the MCHIP’s final adverse decision. The written ruling is binding on both the MCHIP member and the MCHIP to the same extent to which each would have been bound by a judgment entered in an action at law or in equity with respect to the issues which the impartial external entity examined in its review. [TOP]


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