Office of the General Counsel
The Department of Health's Independent Review Organization Appeal Process
This program is not available to members in the Medicaid Program. Members enrolled in the Medicaid Program can file appeals under Medicaid's fair hearing rules with the Office of Fair Hearings, Department of Human Services.
Any health benefits plan member, or a representative acting on behalf of a health benefits plan member with the member's consent, who is dissatisfied with the results of a health benefits plan's internal appeal process shall have the right to pursue his or her appeal to the Director of the Department of Health.
A member or a member's representative must comply with both the informal and formal internal review processes of the health benefits plan before an appeal can be made to the Director of the Department of Health, unless the health benefits plan does not comply with the established deadlines for the informal internal review and formal internal review process. The health benefits plan must make its determination in accordance with the medical exigencies of the case. However, it shall not exceed 14 business days for the informal internal review, 30 business days for the formal internal review, or 48 hours for all urgent or emergency reviews.
An appeal to the Director of the Department of Health must be made within 30 business days of receiving a final formal internal review decision from the health benefits plan. An independent review organization designated by the Director will determine whether the member was deprived of a medically necessary covered service. The Director shall assign each appeal request to an approved independent review organization.
Preliminary Review by the Department of Health
Upon receipt of a request for an appeal, the Department will conduct a preliminary review of the appeal. The Department will accept the appeal if it determines that:
- The individual was a member of the health benefits plan at the time of the action on which the appeal is based
- The health care service which is the subject of the appeal appears to be a service covered by the health benefits plan
- The member or member representative has fully complied with the internal grievance processes of the health benefits plan
- The member or member representative has provided all information required by the Director to make the preliminary determination. This information includes the appeal form, a copy of any information provided by the health benefits plan regarding its decision to deny, reduce, or terminate the covered service, and a fully executed release, so that the Department can obtain necessary medical records from the health benefits plan and from other relevant health care providers if pertinent
The Director of the Department of Health will complete the preliminary review and will notify the member or the member's representative in writing as to whether the appeal has been accepted for processing. If the appeal is not accepted, the Director shall inform the member or member's representative of the reasons therefor within five business days of receipt of the request.
Full Review of Appeal by an Independent Review Organization
Upon receipt of the request for appeal from the Department, the independent review organization shall conduct a full review to determine whether, as a result of the health benefits plan's determination, the member was deprived of medically necessary covered services. In reaching this determination, the independent review organization shall take into consideration all information submitted by the parties, and any other information deemed appropriate in the opinion of the independent review organization, including pertinent medical records; consulting physician reports; any applicable generally-accepted practice guidelines developed by the federal government, national or professional medical societies, boards, or associations; and any applicable clinical protocols and /or practices developed by the health benefits plan.
- The independent review organization shall complete its review and issue its recommended decision as soon as possible in accordance with the medical exigencies of the case. Except as provided herein, the review period shall not exceed 30 business days, or 72 hours in the case of an expedited appeal, from the time the Director assigns the appeal to the independent review organization.
- The independent review organization shall complete its review and issue its recommended decision as soon as possible in accordance with the medical exigencies of the case. Except as provided herein, the review period shall not exceed 30 business days, or 72 hours in the case of an expedited appeal, from the time the Director assigns the appeal to the independent review organization.
- The independent review organization may extend its review for a reasonable period of time if necessary due to circumstances beyond its control. In this event the independent review organization shall, prior to the conclusion of the 30 business day review period, provide written notice to the member or member's representative, to the health benefits plan, and to the Department, setting forth the status of its review and the specific reasons for the delay.
- The independent review organization will notify the Department when a health benefits plan fails to comply with requests for information or with any other aspect of the external review process.
- The independent review organization's recommendation must be written and signed by the medical director. It shall indicate each and every basis for the independent review organization's recommendation. If the independent review organization determines that the member was deprived of medically necessary covered services, it shall recommend the appropriate covered health care services the member should receive. The Director shall forward copies of the recommendation to the member or the member's representative and to the health benefits plan.
- Within five business days of the receipt of the recommendation of the independent review organization, the health benefits plan shall submit a written report to the Director indicating whether it will accept and implement or reject the recommendations of the independent review organization. In the case of a rejection, the health benefits plan shall specifically indicate, in writing, each and every basis for its rejection of the independent review organization's recommendation.
Before You Mail Your Appeal
- For member representatives filing on behalf of a health benefit plan member, attach a copy of the member's consent.
Important: Send copies of any requested documents.
Do not send original documents, as they will not be returned.
If you have any questions, please call (202) 442-5979.
District of Columbia
Department of Health
Office of the General Counsel
Grievance and Appeals Coordinator
825 North Capitol Street, NE, Room 4119
Washington, DC 20002
