You should submit your request for an external review to the Virginia Bureau of Insurance (“Bureau”) within 120 days from the date that your insurer sent you the final decision.^[10]

Information. You can find a copy of the request Form 216-A here. You should include the following information with your request:

• The name of the applicant;
• The name, address, email address, telephone number, and date of birth of the covered person;
• The name, address, and telephone number of the insurance company;
• Insurance identification number and insurance claim or reference number;
• Your employer’s name and telephone number;
• The name and address of your treating health care provider;
• The name and telephone number of the contact person at your health care provider’s office; and
• The reason for the denial.^[11]

If you are requested an expedited external review, your health care provider must complete a Form 216-C “Physician Certification Expedited External Review Request” certifying that a delay in treatment of your condition would seriously jeopardize your life, health, or ability to regain function. A copy of the Form 216-C can be found here. If your claim involves emergency services and you have not yet been discharged from an inpatient facility (such as a hospital), you do not need to complete Form 216-C though.^[12]

Supporting document. You should include the following documents with your request:

• A signed medical records release form (included in request packet);
• A copy of your insurance card;
• A copy of the final determination letter from your insurance company; and
• Any additional or new information and documentation not included with your request for an internal appeal.^[13]

Submitting an external review. You can submit your request by fax to (804) 371-9915, by email to [email protected], or by mail to the following address:

State Corporation Commission
Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218^[14]