How to appeal a health insurance denial in Washington
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. Washington lets you ask an independent reviewer to decide, through Washington State Office of the Insurance Commissioner. The deadline to ask: up to 180 days to file a request for external review after the insurer's final internal appeal decision.
Does this apply to you? State external review covers plans regulated by Washington: 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 Washington
Up to 180 days to file a request for external review after the insurer's final internal appeal decision
The IRO must decide within 72 hours of receiving an expedited request. You can ask for expedited internal and external review at the same time (concurrent expedited review), and the insurer can't make you finish the internal appeal first.
Free
State-regulated plans (insurance bought in Washington or through an employer that buys insurance). Self-funded employer plans use the federal process. Medicare and TRICARE have their own appeals.
There is no OIC form. Ask your insurer for an independent review (the final appeal letter explains how). The insurer assigns the next IRO from OIC's rotation and must tell you which IRO within one day, and you then have 5 business days to send the IRO more information. A standard decision comes within 15 days after the IRO has the information it needs or 20 days after referral, whichever is earlier.
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 Washington?
Up to 180 days to file a request for external review after the insurer's final internal appeal decision
Can I get a fast external review in Washington?
The IRO must decide within 72 hours of receiving an expedited request. You can ask for expedited internal and external review at the same time (concurrent expedited review), and the insurer can't make you finish the internal appeal first.
Does external review cost anything in Washington?
Free
Do Washington’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
- WAC 284-43-3150
A statement that the appellant has up to one hundred eighty days to file a request for external review
- RCW 48.43.535
within not more than seventy-two hours after the receipt of the request for expedited external review
- WAC 284-43A-140
Provide IRO review without imposing any cost to the appellant or their provider
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.