How to appeal a health insurance denial in District of Columbia
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. District of Columbia lets you ask an independent reviewer to decide, through DC Department of Health Care Finance, Office of Health Care and Public Benefits Ombudsman & Bill of Rights. The deadline to ask: within 4 months from receipt of the written decision of the formal internal appeal panel.
Does this apply to you? State external review covers plans regulated by District of Columbia: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in District of Columbia
Within 4 months from receipt of the written decision of the formal internal appeal panel
For urgent or emergency care the independent review organization decides within 72 hours, and the Ombudsman office must say within 24 hours whether the appeal is accepted. You can apply for expedited external review at the same time as an expedited internal appeal.
Free
Insured plans (HMOs and health insurance) issued in the District of Columbia. Self-funded employer plans use the federal process.
By law external appeals are filed with the Director of the Department of Health Care Finance through the Office of Health Care Ombudsman & Bill of Rights (441 4th Street NW, Suite 250N, Washington, DC 20001; fax 202-478-1397; healthcareombudsman@dc.gov), not with DISB; include a letter, the insurer's decision and a signed medical-records release. DISB (202-727-8000) handles appeals of coverage rescissions and general insurance complaints. Medicare and Medicaid enrollees use their own appeal systems.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in District of Columbia?
Within 4 months from receipt of the written decision of the formal internal appeal panel
Can I get a fast external review in District of Columbia?
For urgent or emergency care the independent review organization decides within 72 hours, and the Ombudsman office must say within 24 hours whether the appeal is accepted. You can apply for expedited external review at the same time as an expedited internal appeal.
Does external review cost anything in District of Columbia?
Free
Do District of Columbia’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- D.C. Code § 44-301.07: External appeals process for matters other than rescissions
To initiate an external appeal, a member or member representative shall, within 4 months from receipt of the written decision of the formal internal appeal panel, file a written request with the Director.
- DC Office of Health Care Ombudsman and Bill of Rights: Grievances/Appeals Fact Sheet (revised 9/15/2025)
The member has four (4) months after receipt of the health benefits plan’s final decision to file an appeal
- D.C. Code § 44-301.01: Definitions
“Director” means the Director of the Department of Health Care Finance.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.