How to Appeal a Health Benefits Plan's Decision to Deny, Reduce, Limit, Terminate, or Delay Covered Health Care Services.

Every health benefits plan member has the right to appeal a decision by the health benefits plan that results in a denial, reduction, limitation, termination, or delay in covered health care services. Under the District of Columbia law and regulations, each health benefits plan is required to provide members with the opportunity to resolve an appeal through a two-stage internal grievance process. If a member is dissatisfied with the results from the health benefits plan's internal grievance process, the law and regulations provide the member with the right to an external appeal by an independent review organization (IRO). There is no cost to file the appeal.

An explanation of the appeal process should be contained in the plan's member handbook. Also, at each stage of the internal grievance process, the health benefits plan should advise the member about the next available level of appeal. The appeal can be filed either by the member or by the member's representative acting on behalf of a member with the member's consent.

At the first stage of the grievance process, the individual filing the grievance will have the opportunity to discuss the grievance with the medical director and/or the physician or health care provider designee who rendered the decision. If the grievance is not resolved satisfactorily, it can be pursued to the second stage. At the second stage, the health benefits plan will select a panel of physicians, advanced practice registered nurses, or other health care professionals who have not been involved in the case to review the grievance. The panel can be composed of health care professionals who are part of the health benefit plan's network, or outside consultants in the appropriate specialty. If the health benefit plan maintains its denial at the conclusion of this stage, it must provide the individual with written notification of and reasons for the denial as well as instructions and forms on how to file an external appeal.

To file an external appeal, the health benefits plan member, or a representative, must submit a letter, with appropriate documents to the Department of Health, Office of the General Counsel, Grievance and Appeals Coordinator, within 30 business days of receipt of the health benefit plan's denial. The Department will review the letter with documents to ensure compliance with the Health Benefits Plan Members' Bill of Rights law and regulations, and then it will forward the letter with documents to an independent review organization. The independent review organization will conduct a full review of the case. If the independent review organization determines that the member was deprived of medically necessary covered services, it will recommend to the director of the Department the appropriate covered health care services the member should receive. The director shall forward copies of the recommendation to the member or member representative and the health benefits plan. The health benefits plan in turn is required to notify each of the parties whether it will accept the independent review organization's recommendations. If not, it must explain the reason for its rejection.