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Virginia gets the word out on external review of HMO denials

Although Virginia has had an external review law on the books since 1999, the state's Bureau of Insurance is still trying to get the word out to consumers that there is help available when HMOs deny them needed health benefits or services. Virginia is one of more than 30 states that have an external review process.

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According to the bureau, the law applies to patients covered by insurance contracts written in Virginia by managed care health insurance plans, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

Eligible patients may file an external review appeal through the Bureau of Insurance after they have exhausted all internal appeals with their insurance company. (Read How to appeal a claim denial.) The appeal must be filed within 30 days of the final decision by the insurance company to deny coverage. The minimum claim amount must exceed $300 in order to appeal, and there is a $50 filing fee for any appeal.

Most Virginia state employees and persons covered by federal employee health plans, Medicaid, Medicare, and self-funded health insurance plans are not eligible to file appeals for external review. In addition, if a person's insurance contract contains an exclusion regarding a particular treatment, that claim is not eligible for an external appeal.

The bureau has contracted with three independent health entities to investigate external review cases and prepare reports that the bureau uses to make a final decision. These independent companies contract with doctors to review appeals according to their expertise. Additional information and external appeal forms are available on the Virginia Bureau of Insurance Web site.

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