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External Managed Care Health Insurance Appeals in Virginia

After you have exhausted all internal appeals regarding a decision made by your MCHIP, you may file for an external appeal. If your appeal is accepted, the Bureau will ask an independent healthcare review organization that is not affiliated with your MCHIP to conduct a review of your appeal. You, your treating physician, and your MCHIP will be asked to give the review organization all medical information pertinent to your appeal.

The review organization will make a written recommendation to the Commissioner of Insurance who will review the recommendation to ensure that it is not arbitrary or capricious. The Commissioner will then issue a written ruling that will uphold, reverse, or modify the decision made by your plan. That ruling is binding and cannot be appealed.

Qualifications to Appeal a Decision Made by your MCHIP

The patient must be covered by a contract issued in Virginia by a MCHIP.
After exhausting all internal appeals, unless an expedited review has been requested, patients who have been denied coverage because their insurance plan determines the care was not medically necessary or involved experimental or investigative procedures, can file for an external review. All appeals must be filed within 30 days of the final decision of the patient's insurance plan to deny coverage.
Patients must be covered by an eligible insurance plan, which disqualifies self-insured (or self-funded) ERISA plans, Medicare, and Medicaid. Also, persons covered by federal employee health plans are not eligible to file appeals for external review with the Bureau.
To be eligible for appeal, the patient's claim must exceed $300. There is a $50 filing fee with any appeal. This fee may be waived based upon financial hardship.

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Virginia Consumers Guide to Health Insurance:

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