OHA: External Appeal Processes

Coverage Problems

External Appeals Processes

Eligibility Requirements

There are two ways in which you might be eligible for an external review. The first is through a process faciliated by the Connecticut Insurance Department. You can use this process if you are in a fully-insured plan or the state employee plan. The second is through your employer or plan administrator if you are in a non-grandfathered self-insured plan. (If you are unsure whether you have the right to external review, you should contact your plan or OHA for more information).

To be eligible for the external appeal process facilitated by the Connecticut Insurance Department, you must satisfy the following requirements:

  • You must have exhausted the internal appeals procedure of your managed care plan OR your carrier must have waived the internal appeal process
  • You may be eligible for an expedited appeal if the denial may cause or make worse an emergency or life threatening situation. If you qualify, you may file an expedited external appeal immediately following a denial.
  • You must file for an external appeal within 120 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 basis for the denial must be one of the following:
    • The benefit does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of the health care service, or
    • The health carrier considers the drug, procedure or therapy to be experimental and or/investigational, or
    • The health carrier has made an adverse determination involving eligibility to participate in the health carrier's health benefit plan, or
    • The health carrier has rescinded coverage due to an alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact.
  • 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; and
  • A non-refundable filing fee of $25 is required.

The CT External Appeal Process

The Connecticut Insurance Department contracts with independent entities to review appeals. 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 five business days (two business days for expedited appeals) 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.

When determined eligible, 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. (Two business days for expedited appeals) 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 download or call the Department of Insurance at (860) 297-3910 for copies of the External Appeal Consumer Guide and the External Appeal Application.

Outside CT or Self-Funded Plan External Process

The external appeal process for plans that are regulated by other states depends upon the law of the state in which your policy is written. However, all state regulated plans are required to follow similar processes as required by federal law.

If you are in a self-insured plan, your right to review will depend on whether you are enrolled in a non-grandfathered self-insured plan, as defined by federal law. If you are unsure whether you are in a grandfathered or non-grandfathered self-insured plan, call your employer or plan administrator to find out or call OHA for assistance.

Contact the Office of the Healthcare Advocate when you need help filing the external or expedited appeal by calling toll free 1 (866) 466-4446.