Step 3:
Appeal process
Generally speaking, this is the appeals process:
- You file your appeal with your health plan in writing (your health plan may provide a form). If you are requesting an expedited appeal due to a clinically urgent situation, you may file your appeal verbally or in writing.
- Depending on the laws that regulate your plan, your decision could come back in 72 hours if it's urgent, or 30 days otherwise.
- If the decision is not reversed on the first appeal, and if you have your plan through an employer, your carrier may allow a second level of internal appeal.
- If you have completed your internal appeal or appeals and the insurer has not reversed its decision, you may be eligible for external review. You are eligible for an external review if the decision denying coverage for your service was based on a medical judgment. This final appeal level is a review by an independent reviewer (Independent Review Organization or IRO). An IRO review is a medical file review by a third-party expert, chosen by the Oregon Insurance Division, who is not affiliated with your insurance company.
- If you decide to file and are granted an external appeal, the IRO assigned to your appeal:
- Must notify you and your health plan of a decision within the timeframe allowed.
- Must make a decision that is binding to the health plan. As a last option to overturn the denial, you may pursue legal action.
- Must notify you and your health plan of a decision within the timeframe allowed.
Currently, all health plans allow at least one opportunity to request reconsidering a denial, and some allow for more opportunities.
