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State guide

Rhode Island

Pick the kind of plan you have to see who to call first. Rhode Island can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Rhode Island usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Rhode Island Office of the Health Insurance Commissioner (OHIC). See the at-a-glance box.

    Call (401) 462-9517

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Rhode Island.

    Medicaid in Rhode Island

  • Medicare

    Rhode Island State Health Insurance Assistance Program (SHIP), Rhode Island Office of Healthy Aging gives free counseling. Or call 1-800-MEDICARE.

    Call 888-884-8721 1-800-633-4227

The short version for Rhode Island

Rhode Island has a free statewide helpline, run by the Rhode Island Parent Information Network (RIPIN), that helps people with any kind of health coverage fight denials and medical bills. State law lets you take a medical-judgment denial to an independent review organization within four months, with no minimum claim amount, and requires your insurer to keep covering ongoing treatment while an internal appeal is pending. You request the outside review through your insurer rather than through the state, and the insurer may charge up to $25.

At a glance: independent review for plans Rhode Island regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Rhode Island Office of the Health Insurance Commissioner (OHIC) · (401) 462-9517
Independent review
A state process (External appeal)
Deadline to request it
At least 4 months after you receive the decision on your final internal appeal
Cost
Up to $25, refunded if you win and waived if paying would be a financial hardship; no more than $75 in a plan year
Decision time
Within 10 calendar days after the reviewer has all the information it needs, and no later than 45 calendar days after the request; fast track: 72 hours for urgent or emergency care; for a drug that is not on the plan's list, 72 hours, or 24 hours if the original request was expedited

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Office of the Health Insurance Commissioner's complaints page sorts plans this way: it handles commercial health insurance; self-funded plans from an employer (often larger companies) go to the U.S. Department of Labor; Medicaid plans go to the Rhode Island Executive Office of Health and Human Services; Medicare plans go to the federal Centers for Medicare & Medicaid Services; and self-funded government employer plans (such as State of Rhode Island or city employee plans) go to the federal government. If you are not sure which kind you have, ask your employer's benefits office or call the RIPIN helpline, which helps regardless of plan type.

Independent (external) review

Process
A state process. Run by Independent review organizations approved by the Rhode Island Health Insurance Commissioner, chosen in rotation from a registry the Commissioner specifies.
Where you file
insurer
How
After your insurer's final internal appeal denial, ask the insurer (or its review agent) for an external appeal, using the contact details in the denial letter. The insurer must forward your request to an independent review organization picked by rotation, and you then get at least 5 business days to send the reviewer extra information. The RIPIN helpline (401-270-0101) can help you prepare the request for free.
Which denials qualify
Denials that involve medical judgment or clinical criteria, such as a finding that care is not medically necessary or appropriate, denials of treatment as experimental or investigational, and denials of a prescription drug because it is not on the plan's drug list. There is no minimum dollar amount. Purely administrative denials (for example, the service is simply not a covered benefit) are not covered by this process.
Appeal to the plan first?
Yes. Exceptions: the insurer or its review agent failed to follow the required internal appeal rules (the internal appeal is then treated as finished), or you ask for an expedited external appeal at the same time as an expedited internal appeal.

Official page

General rules and what to send: how external review works, how to request it.

Free help in Rhode Island

Medicare and Medicaid in Rhode Island

Medicare counseling
Rhode Island State Health Insurance Assistance Program (SHIP), Rhode Island Office of Healthy Aging · 888-884-8721 . Free help with Medicare appeals.
Medicaid agency
Rhode Island Executive Office of Health and Human Services (EOHHS), Rhode Island Medicaid
Fair hearing deadline
For eligibility decisions: within 35 days after the date at the top of the notice. For a service denied by a Medicaid managed care plan: within 120 calendar days of the plan's appeal decision. Your notice states the deadline that applies to you.
Good to know
If a Medicaid managed care plan denied a service, you must appeal to the plan first, within 60 calendar days of its decision; to keep services going during that appeal, tell the plan within 10 calendar days. You can then ask for a State Fair Hearing by calling the EOHHS Appeals Office at 401-462-2132, and you may ask for an external appeal by an independent review organization (within 4 months) at the same time. For other notices, you can generally keep benefits unchanged only if you appeal within 10 days of receiving the notice. Eligibility appeals can be filed online at healthyrhode.ri.gov or by calling HealthSource RI at 1-855-840-4774.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. You get at least four months to ask for an external appeal by an independent review organization, there is no minimum claim amount, the fee is capped at $25, and the decision is binding on the insurer, which must pay or provide the care without delay.

    R.I. Gen. Laws § 27-18.9-8; 230-RICR-20-30-14 § 14.8

  • Denial notice. A denial based on medical judgment must give the specific reasons, the plan rules or clinical criteria relied on, the clinical judgment behind it, how to get your claim file free of charge, and how to appeal; insurers must decide urgent requests within 72 hours, requests before care within 15 calendar days and claims after care within 30 calendar days.

    R.I. Gen. Laws § 27-18.9-6

  • Other. You get at least 180 days to file an internal appeal, a medical-judgment appeal must be reviewed by a clinician in the same or a similar specialty who was not involved before, you may see your whole file, and the insurer must continue coverage of ongoing treatment while the appeal is pending.

    R.I. Gen. Laws § 27-18.9-7

  • Prior authorization. Under a three-year pilot that began October 1, 2025, insurers may not require prior authorization for any admission, item, service, treatment or procedure ordered by a primary care provider in the normal course of primary care (prescription drugs are excluded).

    R.I. Gen. Laws § 27-18.9-16 (Rhode Island Prior Authorization Reform Act of 2025; expires October 1, 2028)

  • Mental health parity. Health plans must cover mental health and substance use disorder treatment on the same terms as other illnesses, with no annual or lifetime dollar limits and no stricter non-financial limits (such as tougher medical-necessity review) than they apply to medical and surgical care.

    R.I. Gen. Laws § 27-38.2-1

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. CMS: State External Appeals Review Processes (table updated July 9, 2024)
  2. CMS: Consumer Assistance Program contacts, Rhode Island
  3. Office of the Health Insurance Commissioner: Consumer Protection
  4. Office of the Health Insurance Commissioner: Health Insurance Complaints
  5. R.I. Gen. Laws § 27-18.9-8, External appeal procedural requirements
  6. 230-RICR-20-30-14, Benefit Determination and Utilization Review (Rhode Island Department of State)
  7. R.I. Gen. Laws § 27-18.9-6, Non-administrative benefit determination notifications
  8. R.I. Gen. Laws § 27-18.9-7, Internal appeal procedural requirements
  9. R.I. Gen. Laws § 27-18.9-16, Prior authorization reduction and improvement
  10. R.I. Gen. Laws § 27-38.2-1, Coverage for treatment of mental health and substance use disorders
  11. RIPIN Call Center
  12. RIPIN: Free Health Insurance Help for Rhode Islanders
  13. Rhode Island Attorney General: Healthcare Advocacy
  14. Rhode Island Legal Services: Public Benefits Group
  15. Rhode Island Office of Healthy Aging: Medicare Counseling
  16. EOHHS Appeals Office
  17. Stay Covered Rhode Island: File an Appeal
  18. EOHHS: Rhode Island Managed Medicaid Model Member Handbook (2021)
  19. EOHHS: Notice of appeal rights (deadlines and continued benefits)
Not confirmed (7)
  • Not confirmed. externalReview.whereToFile / howToFile — taken from the statute and regulation (the insurer or its review agent 'shall provide for' the external appeal and forwards it to the reviewer); the Office of the Health Insurance Commissioner has no consumer page spelling out where to send the request, so the exact address comes from each insurer's denial letter
  • The independent review request form. no state-published request form found; insurers supply their own
  • Not confirmed. externalReview.decisionsDatabaseUrl / statisticsNote — no published external appeal decisions or overturn rate found on the Office of the Health Insurance Commissioner site
  • Free consumer help programs. RIPIN's own site gives 401-270-0101 as the helpline and says toll-free 1-855-747-3224 is its Healthcare Advocate line for people with both Medicare and Medicaid, while the Office of the Health Insurance Commissioner's site lists 1-855-747-3224 as the toll-free RIREACH number; 401-270-0101 appears on both
  • Free consumer help programs. the Rhode Island Legal Services page loaded with what looked like injected spam link text; the phone number was confirmed on the state's staycovered.ri.gov page, but check the site before linking to it
  • Not confirmed. medicaid.fairHearingDeadline / notes — the managed care figures (60 days to appeal to the plan, 120 days for a State Fair Hearing, 401-462-2132) come from the state's 2021 model member handbook, not a current web page; the EOHHS Appeals Office page still carries an old COVID-19 notice and states no deadline
  • Not confirmed. stateLaws step-therapy — no enacted general step therapy exception law found; a 2026 bill (H 7539) was held for further study, so none is listed

Sources last checked . Found a mistake? Report it.