How to appeal a health insurance denial in South Carolina
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. South Carolina lets you ask an independent reviewer to decide, through South Carolina Department of Insurance. The deadline to ask: within four months of receiving notice that an adverse determination has been made under the insurer's internal appeal process (SCDOI Bulletin 2011-04, non-grandfathered plans); the state statute still says 60 days.
Does this apply to you? State external review covers plans regulated by South Carolina: 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 South Carolina
Within four months of receiving notice that an adverse determination has been made under the insurer's internal appeal process (SCDOI Bulletin 2011-04, non-grandfathered plans); the state statute still says 60 days
Decision within 72 hours of receipt of the request; no filing deadline for expedited requests, and you may pursue expedited external review while simultaneously pursuing an expedited internal appeal. A treating physician's certification is required.
Free
State-regulated plans (insurance bought in South Carolina or through an employer that buys insurance). Self-funded employer plans use the federal process.
Send a written request to your health carrier with a signed medical-records release; the carrier notifies SCDOI, which assigns an IRO by rotation. SCDOI Bulletin 2011-04 replaced the statute's 60-day deadline and $500 minimum-claim rule for non-grandfathered plans, but SCDOI's posted Patient's Guide still shows the old 60-day/$500 terms, and grandfathered plans may still use them, so file within 60 days if you can. The State Health Plan (PEBA) is self-funded and not under SCDOI.
Who to contact
- South Carolina Department of Insurance
- External review information and forms
- Consumer help line: 800-768-3467
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 South Carolina?
Within four months of receiving notice that an adverse determination has been made under the insurer's internal appeal process (SCDOI Bulletin 2011-04, non-grandfathered plans); the state statute still says 60 days
Can I get a fast external review in South Carolina?
Decision within 72 hours of receipt of the request; no filing deadline for expedited requests, and you may pursue expedited external review while simultaneously pursuing an expedited internal appeal. A treating physician's certification is required.
Does external review cost anything in South Carolina?
Free
Do South Carolina’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
- SCDOI Bulletin 2011-04: Compliance with the External Review Requirements of the PPACA
A request for external review must be made within four months of receiving notice than an adverse determination has been made under the insurer's internal appeal process.
- SCDOI - External Reviews - Independent Review Organizations
These requirements were updated by SCDOI Bulletin 2011-04 to comply with external review requirements of the Patient Protection and Affordable Care Act.
- SCDOI Patient's Guide to External Review
The review would cost you nothing.
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.