OHA: Internal Appeals Process

Coverage Problems

Internal Appeals Process

Health plans must have an internal appeals process that consumers can use to appeal a decision to deny or curtail coverage of care.

Connecticut has a law requiring managed care plans to have an internal appeals system available for consumers who disagree with a plan decision (sometimes called an "adverse determination"). Those internal appeals requirements must include the following features:

  • Notice: The consumer must be told in writing that they have the right to appeal the plan's decision along with information on how to file such an appeal. The patient also must be notified in writing of the reviewer's decision, provided the rationale for the decision and given copies of documentation supporting that decision upon request.
  • Timeline: Plans must respond to a patient's appeal in a timely manner-- usually within 15-30 days. In emergent or urgent cases, plans have to respond generally within 72 hours, but fully-insured (state regulated) plans must respond within 24 hours for most mental health and substance use service requests. 
    • Review by qualified professionals: Plans must have a qualified health care professional (generally a physician trained in the field of care that is involved) review the case. This doctor should not have been involved with the initial decision to deny coverage.
    • Levels of appeal: Health plans must provide for one level of appeal. At least one Connecticut plan provides for a second voluntary level of internal appeal. A clinical peer must review the request for coverage as part of the internal appeal process.
    • Care during the review process: Some health plans continue to pay for the care in dispute while the appeal is being considered. If your case involves an urgent concurrent review, the plan must provide coverage during the 72 hour review process.

    Managed care plan enrollees have the right to question decisions regarding their health care coverage. Connecticut state law requires that each managed care health plan establish and maintain an internal grievance procedure to insure that enrollees may seek a review of any grievance that may arise from the plan's action or inaction.