External Review of Health Plan Disputes
Members of health plans issued by private health insurance companies may request an external review of certain coverage denials. This external review will be performed by a private independent review organization which contracts with doctors who give medical opinions. This option is not available for Medicare and Medicaid members or for members of self-funded plans where the insurance company is merely acting as a third party administrator.
- From the date of the coverage denial, a member has 130 days to request an external review.
- A filing fee of $15 is due payable to “Department of Commerce and Consumer Affairs."
- Include a copy of the final internal determination
- Include a release of medical records
- Include a conflict of interest disclosure. (A form of release and conflict of interest disclosure can be obtained from your health plan.)
In the cover letter for the request, a member should explain in detail why they believe the coverage decision made by the health plan was in error. The $15 filing fee is refundable if the independent review organization agrees with the member.
There are three types of external reviews and the member should try to identify which type of review is being requested.
1. The first type of review is a standard external review which covers denials which are based on medical necessity, appropriateness, health care setting, level of care, or effectiveness.
2. The second type of review is an expedited external review, which is for cases involving a medical emergency, where the patient cannot wait to receive medical treatment.
3. The third type of review is a review of an investigational or experimental procedure denial. These are cases in which the health plan has determined that the procedure is so new that it is not validated as standard medical practice.
Not all types of coverage denials can be appealed. If it is determined that your request for external review is not valid, then it may be rejected. For example, if a health plan determines that your medical procedure was not covered because it was the subject of a specific exclusion in the health plan that may not end up being the type of medical denial that can be reviewed.
You may contact the Insurance Division for advice on this topic at 808-586-2804.