• You must have exhausted the internal appeals procedure of your managed care plan
   
• You must file for an external appeal within 60 days of receiving the written notification that the internal appeals have been exhausted
   
• You must be an enrollee in the managed care plan at the time the service was requested
   
• You must appeal for a service or procedure that is covered in your contract
   
• The denial of coverage must be based on "medical necessity" (according to the NCQA the determination and intervention recommended by a treating practitioner is (1) the most appropriate service for the individual in question, considering potential benefits and harms to the individual, and (2) known to be effective in improving health outcomes)
   
• Your appeal cannot be for workers’ compensation claims
   
• Your plan cannot be a "self-insured" plan
   
• Your plan cannot be offered as part of a Medicaid or Medicare program
   
• A non-refundable filing fee of $25 is required

The Connecticut Insurance Department contracts with an independent entity to review the appeal. If your appeal does not meet the conditions required for eligibility for external appeal (outlined previously), your appeal will be ruled ineligible. The external appeal entity will contact you and the Insurance Commissioner within 5 business days of its receipt as to whether the appeal has been accepted or denied for full review. If the appeal is denied in the preliminary phase, the external appeal process ends. The reviewing entity will complete the full review and forward its recommendation to the Insurance Commissioner within 30 business days of completing the preliminary review. The Insurance Commissioner will accept the decision of the external appeal entity and notify you and your managed care plan of the decision.

You can call the Department of Insurance at (860) 297-3862 for a copy of the External Appeal Consumer Guide and the External Appeal Application. These documents are also available on the State of Connecticut Insurance Department’s web site: www.ct.gov/CID/

Appeals Process Summary

Other Related Links:

Determine the Problem

3 Step Complaint Process

How to Write an Appeal Letter

Internal Appeals Process

Download Consent Statement