How to appeal a health insurance denial in Vermont
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. Vermont lets you ask an independent reviewer to decide, through Vermont Department of Financial Regulation. The deadline to ask: within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer.
Does this apply to you? State external review covers plans regulated by Vermont: 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 Vermont
Within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer
Urgent and emergency appeals are expedited, and the IRO must decide no more than 3 days after receiving the request. You can file an expedited external appeal at the same time as an urgent internal appeal. After hours, call DFR's urgent external appeals line at 802-232-2878.
$25 filing fee (capped at $75 a year), waived for financial hardship and paid back by the insurer if the IRO reverses the denial
State-regulated plans (insurance bought in Vermont or through an employer that buys insurance). Self-funded employer plans use the federal process unless they volunteer for Vermont's. Vermont Medicaid has its own appeals process.
You only have to finish the insurer's first-level internal appeal. Then send the DFR External Appeals Application and the fee to DFR by mail, email or fax. Don't email medical records; DFR will tell you how to send them securely. The law only allows review when the service costs the plan at least $100. Free help: Office of the Health Care Advocate, 800-917-7787. DFR's toll-free main line is 833-337-4685.
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 Vermont?
Within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer
Can I get a fast external review in Vermont?
Urgent and emergency appeals are expedited, and the IRO must decide no more than 3 days after receiving the request. You can file an expedited external appeal at the same time as an urgent internal appeal. After hours, call DFR's urgent external appeals line at 802-232-2878.
Does external review cost anything in Vermont?
$25 filing fee (capped at $75 a year), waived for financial hardship and paid back by the insurer if the IRO reverses the denial
Do Vermont’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
- Vermont DFR: Healthcare External Appeal
Your external appeal must be requested within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer.
- 8 V.S.A. § 4063
Pay an application fee of $25.00 for each request for an independent external review of an appealable decision not to exceed a total of $75.00 annually.
- Vermont DFR Rule H-2011-02
but in no event more than three (3) days after receipt of the request for an independent 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.