How to appeal a health insurance denial in Virginia
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. Virginia lets you ask an independent reviewer to decide, through Virginia State Corporation Commission, Bureau of Insurance. The deadline to ask: A complete request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an External Review.
Does this apply to you? State external review covers plans regulated by Virginia: 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 Virginia
A complete request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an External Review
The IRO decides within 72 hours for medical-necessity denials or 6 business days for experimental/investigational denials. You can file for expedited review when you get the denial, alongside an expedited internal appeal, if waiting would seriously jeopardize your life or health or the denial involves cancer. A physician certification (Form 216-C) is required.
Free
Fully insured plans issued in Virginia (insurance bought in Virginia or through an employer that buys insurance). Self-funded employer plans use the federal process unless they opt in to Virginia's process and the company is headquartered in Virginia.
Call the Bureau first (877-310-6560 or externalreview@scc.virginia.gov). Then send Form 216-A with the signed medical-records release, your insurance card and the final denial letter to the Bureau, not the insurer. The 120 days run until the Bureau receives a complete request. Reimbursement disputes, contract exclusions, dental/vision plans and Medicare/Medicaid/TRICARE are not eligible.
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 Virginia?
A complete request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an External Review
Can I get a fast external review in Virginia?
The IRO decides within 72 hours for medical-necessity denials or 6 business days for experimental/investigational denials. You can file for expedited review when you get the denial, alongside an expedited internal appeal, if waiting would seriously jeopardize your life or health or the denial involves cancer. A physician certification (Form 216-C) is required.
Does external review cost anything in Virginia?
Free
Do Virginia’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
- Virginia SCC: External Review
A complete External Review request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an External Review.
- Va. Code § 38.2-3561
Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination
- Va. Code § 38.2-3562
but in no event more than 72 hours after the date of receipt of an eligible request for an expedited 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.