The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.^[3]

A. Expedited Internal Appeals for Increased Health Risks

You can request an expedited internal appeal if:

• You are currently receiving health care services and you could experience a significantly increased health risk if your insurer denied those services; or
• Your insurer denied a treatment referral, service, procedure, or other health care service and the denial significantly increases the risk to your health.^[4]

To obtain an expedited internal appeal, contact your insurer and request an expedited internal appeal either orally or in writing, depending on your health insurer’s policy.^[5] Your determination letter should provide specific instruction about how to request the expedited internal appeal.

Once you request the appeal, your health insurer should notify you within 24 hours to either (1) ask for any additional information it needs to evaluate the appeal; or (2) to provide you with a decision. If the insurer asked for additional information, it should provide you with a decision within 24 hours of receiving the additional information.^[6]

B. Expedited External Reviews for Urgent Situations

In urgent situations, you can skip the internal and expedited internal appeals processes and request an expedited external review instead. Your situation is urgent in the following circumstances:

• You have a medical condition and waiting 48 hours for treatment would jeopardize your life, health, or your ability to regain function; or
• Your insurer deems your requested treatment “experimental” or “investigational,” and your health care provider certifies that the treatment would be significantly less effective if it is delayed.^[7]