How to appeal a health insurance denial in Rhode Island
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. Rhode Island lets you ask an independent reviewer to decide, through Rhode Island Office of the Health Insurance Commissioner (OHIC). The deadline to ask: at least four (4) months after receipt of the notice of the decision on your final internal appeal.
Does this apply to you? State external review covers plans regulated by Rhode Island: 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 Rhode Island
At least four (4) months after receipt of the notice of the decision on your final internal appeal
For urgent or emergent care the IRO must decide no more than 72 hours after receiving the request (oral notice allowed, written decision within 48 hours). You may apply for expedited external review at the same time as an expedited internal appeal. Non-formulary drug appeals: 72 hours, or 24 hours if expedited.
Plan may charge up to $25 (refunded if the denial is reversed, waived for undue financial hardship, capped at $75 per plan year)
State-regulated plans (insurance bought in Rhode Island or through an employer that buys insurance). Self-funded employer plans use the federal process.
There is no state application form: ask your health plan (or its review agent) for the external appeal as your final appeal notice directs, and the plan assigns an IRO from OHIC's rotational registry. OHIC's consumer help line is RIREACH, run by its partner RIPIN (855-747-3224 toll-free, 401-270-0101); OHIC's own office is 401-462-9517. OHIC covers fully insured commercial plans only; Medicaid (EOHHS), Medicare and self-funded plans go elsewhere.
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 Rhode Island?
At least four (4) months after receipt of the notice of the decision on your final internal appeal
Can I get a fast external review in Rhode Island?
For urgent or emergent care the IRO must decide no more than 72 hours after receiving the request (oral notice allowed, written decision within 48 hours). You may apply for expedited external review at the same time as an expedited internal appeal. Non-formulary drug appeals: 72 hours, or 24 hours if expedited.
Does external review cost anything in Rhode Island?
Plan may charge up to $25 (refunded if the denial is reversed, waived for undue financial hardship, capped at $75 per plan year)
Do Rhode Island’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
- R.I. Gen. Laws 27-18.9-8 (External appeal procedural requirements)
A claimant shall have at least four (4) months after receipt of a notice of the decision on a final internal appeal to request an external appeal by an IRO.
- OHIC - Consumer Protection
For consumer assistance call RIREACH: (855)-747-3224
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.