How to appeal a health insurance denial in Idaho
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. Idaho lets you ask an independent reviewer to decide, through Idaho Department of Insurance. The deadline to ask: within, but not later than, 120 days (four months) from the date of the final denial by the insurance company.
Does this apply to you? State external review covers plans regulated by Idaho: 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 Idaho
Within, but not later than, 120 days (four months) from the date of the final denial by the insurance company
The independent review organization must decide within 72 hours after it receives an expedited request from the Department. The treating provider must certify the urgency, and you can apply for expedited external review at the same time as an expedited internal appeal.
Free (the insurance company pays)
State-regulated plans (insurance bought in Idaho or through an employer that buys insurance). Self-funded employer plans use the federal process.
File with the Department of Insurance (ATTN: External Review, 700 W. State St., Boise ID 83720-0043; fax 208-334-4398) using its required Health Claims External Review Request Form. Attach a copy of the final denial letter and your insurance ID card. Only medical-necessity-type and investigational denials qualify; coverage or eligibility disputes do not. The 800 number is toll-free in Idaho only (main line 208-334-4250), and the statute (Idaho Code 41-5908) says four months, so file within 120 days to be safe.
Who to contact
- Idaho Department of Insurance
- External review information and forms
- Consumer help line: 800-721-3272
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 Idaho?
Within, but not later than, 120 days (four months) from the date of the final denial by the insurance company
Can I get a fast external review in Idaho?
The independent review organization must decide within 72 hours after it receives an expedited request from the Department. The treating provider must certify the urgency, and you can apply for expedited external review at the same time as an expedited internal appeal.
Does external review cost anything in Idaho?
Free (the insurance company pays)
Do Idaho’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
- Idaho DOI: External Review
within, but not later than, 120 days (four months) from the date of the final denial by the insurance company.
- Idaho Code §41-5908 Standard external review
Within four (4) months after the date of issuance of a notice of a final adverse benefit determination
- Idaho DOI: External Review Questions
you are applying for an expedited external review with the Idaho Department of Insurance (DOI) at the same time as applying for an expedited internal review with the health carrier
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.