How to appeal a health insurance denial in Ohio
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. Ohio lets you ask an independent reviewer to decide, through Ohio Department of Insurance. The deadline to ask: within 180 days of the date of the final adverse benefit determination.
Does this apply to you? State external review covers plans regulated by Ohio: 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 Ohio
Within 180 days of the date of the final adverse benefit determination
Expedited external review is decided within 72 hours; urgent requests may be made orally (written confirmation follows), and you can request expedited external review at the same time as an expedited internal appeal.
Free (the health plan pays the cost of the review)
State-regulated plans (insurance bought in Ohio or through an employer that buys insurance). Self-funded employer plans use the federal process.
Send the written request (mail, email or fax) to your health plan, not the Department; the plan enters it in ODI's system, which randomly assigns an Ohio-accredited IRO. Denials based on contract terms with no medical judgment are reviewed by the Department itself rather than an IRO. If the plan says your case is ineligible, you can appeal that to the Department.
Who to contact
- Ohio Department of Insurance
- External review information and forms
- Consumer help line: 800-686-1526
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 Ohio?
Within 180 days of the date of the final adverse benefit determination
Can I get a fast external review in Ohio?
Expedited external review is decided within 72 hours; urgent requests may be made orally (written confirmation follows), and you can request expedited external review at the same time as an expedited internal appeal.
Does external review cost anything in Ohio?
Free (the health plan pays the cost of the review)
Do Ohio’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
- Ohio Revised Code 3922.02
by the covered person to the health plan issuer within one hundred eighty days of the date of the final adverse benefit determination
- Ohio Department of Insurance - Health Coverage and External Review Appeals Process
Those with questions about appealing their insurer's health coverage decisions can call the department's consumer hotline at 800-686-1526.
- Ohio Revised Code 3922.18
The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review
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.