How to appeal a health insurance denial in West 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. West Virginia lets you ask an independent reviewer to decide, through West Virginia Offices of the Insurance Commissioner. The deadline to ask: within four months of receipt of a notice of an adverse determination or final adverse determination.
Does this apply to you? State external review covers plans regulated by West 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 West Virginia
Within four months of receipt of a notice of an adverse determination or final adverse determination
Expedited reviews must be finished within 72 hours, and your treating provider must complete the certification form. You can request expedited external review while still pursuing the internal appeal. Call the OIC first (888-879-9842) for the fastest way to submit.
Free
State-regulated plans (insurance bought in West Virginia or through an employer that buys insurance). Self-funded employer plans use the federal process. Medicaid, CHIP, Medicare and other government programs are not covered.
Send the application and documents to the OIC (OICHealthPolicy@wv.gov or PO Box 50540, Charleston, WV 25305-0540), not to the insurer. Sources conflict on the deadline: the OIC's 2016 request form says 180 days, but the governing rule (W. Va. Code R. § 114-97-6) says four months. File within four months to be safe.
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 West Virginia?
Within four months of receipt of a notice of an adverse determination or final adverse determination
Can I get a fast external review in West Virginia?
Expedited reviews must be finished within 72 hours, and your treating provider must complete the certification form. You can request expedited external review while still pursuing the internal appeal. Call the OIC first (888-879-9842) for the fastest way to submit.
Does external review cost anything in West Virginia?
Free
Do West 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
- W. Va. Code R. § 114-97-6 (LII)
Within four months of receipt of a notice of an adverse determination or final adverse determination, a covered person may file a request for an external review with the Commissioner
- WV OIC: External Review
You must complete and submit the application and all supporting documentation to the West Virginia Offices of the Insurance Commissioner at OICHealthPolicy@wv.gov to request an external review.
- WV OIC: External Review Request Form (2016)
There is no cost to you for an 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.