How to appeal a health insurance denial in Florida
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. In Florida, external review for state-regulated plans goes through the federal process overseen by HHS. The deadline to ask: within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process).
Does this apply to you? State external review covers plans regulated by Florida: 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 Florida
Within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process)
Expedited external reviews are decided as soon as possible and no later than 72 hours after the request is received. Under the federal rule you can request one at the same time as an expedited internal appeal.
Free under the HHS-administered federal process. If your insurer uses its own contracted independent review organization, you can be charged up to $25.
State-regulated plans (insurance bought in Florida or through an employer that buys insurance). Self-funded employer plans use the federal process.
Florida has no state external review program. CMS lists it as an HHS-administered state, and the state's Subscriber Assistance Program for HMO members was repealed effective July 1, 2018. Your final denial letter says whether to file through the HHS/Maximus process (online portal, fax 888-866-6190, or ferp@maximus.com) or with an independent review organization your insurer contracts with directly (Florida Blue, for example, takes requests at its own appeals address), and you must finish the insurer's internal appeal first. DFS Consumer Services handles complaints about Florida-issued policies. Medicaid, Medicare, and self-insured government plans have separate channels.
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 Florida?
Within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process)
Can I get a fast external review in Florida?
Expedited external reviews are decided as soon as possible and no later than 72 hours after the request is received. Under the federal rule you can request one at the same time as an expedited internal appeal.
Does external review cost anything in Florida?
Free under the HHS-administered federal process. If your insurer uses its own contracted independent review organization, you can be charged up to $25.
Do Florida’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
- HealthCare.gov: External Review
You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.
- Florida AHCA: Commercial Managed Care (Subscriber Assistance Program repeal notice)
Effective July 1, 2018, the Subscriber Assistance Program is repealed pursuant Senate Bill 622
- Florida DFS: Health Insurance FAQs
You will need to exhaust the internal appeal process before applying for an external appeal.
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.