In the external appeals process, consumers can request review of their health insurer’s decision to deny coverage for or payment of a service by an independent third-party not related to the insurer or consumer. An external appeal is available if the insurer denies coverage on the basis of medical necessity, or because it determines that the care is experimental or investigational. The external reviewer will either uphold or reverse the insurer’s decision, and the decision is binding on the insurer.
External Appeals Process
- We are accepting external appeal applications;
- Due to COVID-19 Public Health Emergency, application fees for health care external appeals are suspended until further notice.
- Applications must be submitted via email to Beth Sides at Beth.Sides@vermont.gov.
- Do not send medical records over unsecured email; We will contact you with instructions for securely submitting medical records for review.
- All communications relating to external appeals will be conducted via email or phone. Other accommodations may be made on a case-by-case basis—call Beth Sides at 802-828-0184 for more information.
- If you have had health care services which have been denied and you think they should be covered, talk with your doctor or healthcare provider or call your health insurance company to get help understanding the company’s decision. If you are still not satisfied, tell your health insurer you want to file a first level appeal. You must complete the insurer’s first-level internal appeal process… before you can start DFR’s external appeal process. If you are still unhappy with your insurer's decision, only then you may have the right to get an independent review of that decision.
- If you have questions about whether your matter can be externally reviewed, please call Sebastian Arduengo at 802-828-4846. Your medical information will be kept confidential.
You must request an external appeal within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer.
To qualify for an independent external appeal, the insurer must have denied coverage for one of the following reasons:
- The service is not medically necessary, or
- The selection of a health care provider is limited in a way that is not allowed by your contract or by law, or
- The service is considered to be experimental, investigational, or an “off-label” use of a drug, or
- A medically based decision was made that your condition was “pre-existing”, and
- Was a covered benefit under you plan.
If it appears that you qualify, you may complete the attached application or ask us to send you an application. There is a $25 filing fee that may be waived. We will collect documents from you and the insurer and submit them to the Independent Review Organization (IRO). Decisions by the IRO are made within 30 days of receiving all information.
Emergency External Appeal Request
If you have an emergency and need to request an external appeal (and it cannot wait for normal business hours), please call the External Appeals answering service at 888-236-5966. Your call will be returned as soon as possible. This number is only for Health Insurance appeals. If your appeal is not an emergency or medically urgent, please do not use this emergency number, but call again during normal business hours.
If your case is medically urgent or an emergency, timeframes can be shorter. Call us immediately. Your medical information will be kept confidential.