If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:
If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:
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.[5] If you have requested an urgent care appeal, the process should take no more than 72 hours to complete, unless there is vital information missing.[6]
During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Virginia law, you are entitled to request an external review in the following circumstances:
You can also request an expedited external review if your medical situation is urgent. You can file a request for an expedited external review while you file a request for an urgent care appeal.[9]
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:
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:
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]
The independent external review organization should provide a decision within 45 days of receipt of the request for external review.[15] The entire external review process should take no more than 60 days.[16] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[17]
If you are a Virginia resident and have completed the internal and external review processes, you can file a complaint with the Bureau.
Complaint information. Your complaint should include the following information:
Supporting documents. You should submit the following supporting documents with your complaint:
How to submit. The complaint may be submitted by fax to (804) 371-9944, or by mail to the following address:
State Corporation Commission
Bureau of Insurance
Life and Health Division
P.O. Box 1157
Richmond, VA 23218[19]
The Bureau will send a copy of the complaint to your health insurer and attempt to resolve the issue with them.[20] It may take up to 45 days or longer for your claim to be resolved, depending on the complexity of the issue.[21] The Bureau may require the insurance company to comply with the policy (in other words, make the insurer cover the requested treatment or service), issue a citation, or fine the company.
You can contact the Virginia Bureau of Insurance at (804) 371-9691, (800) 552-7945 (in-state), or (877) 310-6560. The Bureau is open from 8:15 a.m. to 5:00 p.m., Monday through Friday.