State guide
Virginia
Pick the kind of plan you have to see who to call first. Virginia can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Virginia usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Virginia State Corporation Commission, Bureau of Insurance. See the at-a-glance box.
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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 Virginia.
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Medicare
Virginia Insurance Counseling and Assistance Program (VICAP) gives free counseling. Or call 1-800-MEDICARE.
The short version for Virginia
Virginia's insurance regulator is the Bureau of Insurance inside the State Corporation Commission (SCC). It runs a free external review and has an Office of the Managed Care Ombudsman that will help you file an appeal with your health plan. Two unusual points: people denied cancer treatment can ask for an expedited external review without finishing the insurer's appeal first, and some self-insured employer plans headquartered in Virginia have opted in to the state process.
At a glance: independent review for plans Virginia regulates
- Main regulator
- Virginia State Corporation Commission, Bureau of Insurance · 1-877-310-6560 (toll free); Life and Health Consumer Services 804-371-9691
- Independent review
- A state process (External Review (independent external review))
- Deadline to request it
- A complete request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an external review
- Cost
- None (the Bureau calls it a free service)
- Decision time
- Within 45 days; fast track: Within 72 hours for medical necessity denials, or 6 business days for experimental or investigational denials
Who regulates health plans
- Virginia State Corporation Commission, Bureau of Insurance
Fully insured health plans issued in Virginia (individual and employer plans bought from an insurance company or health maintenance organization), plus Medicare supplement (Medigap), long-term care, dental and disability policies. It does not regulate most self-insured employer plans, Medicare, Medicaid or TRICARE military coverage.
Phone: 1-877-310-6560 (toll free); Life and Health Consumer Services 804-371-9691. File a complaint online
Independent (external) review
- Process
- A state process. Run by Virginia State Corporation Commission, Bureau of Insurance, which randomly assigns an impartial Independent Review Organization (IRO).
- Where you file
- regulator
- How
- Call the Bureau of Insurance first at 1-877-310-6560 or email externalreview@scc.virginia.gov to talk through your situation and learn which forms you need. Then send the completed External Review Request Form (Form 216-A) following the instructions on the form; urgent requests also need the physician certification (Form 216-C), and experimental treatment denials need Form 216-D.
- Which denials qualify
- Denials of a covered benefit because the service is not medically necessary (including appropriateness, health care setting, level of care or effectiveness) or is experimental or investigational. Not eligible: payment disputes, services your contract excludes, and out-of-network denials unless based on medical necessity. You must be in a fully insured plan issued in Virginia or a self-insured plan that has opted in.
- Appeal to the plan first?
- Yes, you must finish the insurance company's appeal process first. Exception: if the denial involves treatment of cancer you may request an expedited external review without exhausting the insurer's appeals. State law also allows review when the internal appeal is deemed exhausted or waived.
Free help in Virginia
- Office of the Managed Care Ombudsman (Virginia Bureau of Insurance)
Explains appeal rights and helps consumers file appeals, including utilization review appeals, with managed care health insurance plans such as health maintenance organizations and preferred provider organizations; you sign the Life and Health Insurance Complaint/Appeal Form to authorize its help.
Phone: 1-877-310-6560
- Virginia Bureau of Insurance, Life and Health Consumer Services
Investigates complaints about health, Medigap, long-term care, dental and disability insurance on Virginia-issued policies and checks that the company followed Virginia law and your policy; complaints must be filed in writing or online, not by phone or email.
Phone: 804-371-9691
Medicare and Medicaid in Virginia
- Medicare counseling
- Virginia Insurance Counseling and Assistance Program (VICAP) · 1-800-552-3402 . Free help with Medicare appeals.
- Medicaid agency
- Virginia Department of Medical Assistance Services (DMAS), Virginia Medicaid and FAMIS (Family Access to Medical Insurance Security)
- Fair hearing deadline
- 30 days from the date you receive the written notice (the state presumes you receive it 5 days after mailing). For a Medicaid managed care organization decision: 120 days from receiving the plan's final decision, and that 120 days cannot be extended. Your notice states the deadline that applies to you.
- Good to know
- If a Medicaid managed care plan made the decision, you must finish the plan's own appeal first and can only appeal its final decision to the state. Late non-managed-care appeals may be accepted for good cause. You can file through the state's online appeals portal, or by email, fax, mail or phone (DMAS Appeals Division 804-371-8488).
State laws that can help
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Step therapy. Plans must offer a clear process to request a step therapy exception, must grant it when the required drug is contraindicated, would be ineffective, was already tried and stopped, or you are doing well on your current drug, and must answer within 72 hours (24 hours in urgent cases), weekends included.
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Surprise billing. Out-of-network providers cannot balance bill you for emergency services, or for surgical or ancillary services at an in-network facility; you owe only your in-network cost share, and any overpayment must be refunded within 30 business days.
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Prior authorization. Plans that cover emergency department services must cover emergency services without prior authorization, whether in or out of network, and without regard to the final diagnosis.
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External review. Gives you 120 days to ask the State Corporation Commission for external review and removes the requirement to finish the insurer's appeal first when the denial relates to cancer treatment.
Sources and what we could not confirm
- Virginia SCC: External Review
- Virginia SCC: Office of the Managed Care Ombudsman
- Virginia SCC: File A Complaint (insurance)
- Virginia SCC: Consumer Assistance, Outreach and Education
- CMS: State External Appeals Review Processes
- CMS: Virginia Consumer Assistance
- Code of Virginia § 38.2-3561
- DMAS: Virginia Medicaid Client Appeals Process At A Glance (PDF)
- DMAS: Client Appeals Frequently Asked Questions (PDF)
- DMAS: Appeals for Clients
- SHIP National Technical Assistance Center: Virginia
Not confirmed (6)
- How to tell whether the state regulates your plan. no card-based tip was found on the Bureau of Insurance pages loaded; the external review page only says you must be in a fully insured plan issued in Virginia or an opted-in self-insured plan.
- Free consumer help programs. the Ombudsman page was read but its contact block was not captured; the number given is the Bureau of Insurance toll-free line printed on the complaint and external review pages. The Ombudsman's email is Ombudsman@scc.virginia.gov.
- The Medicaid fair hearing page. the address is printed in the DMAS appeals documents; the page itself was not opened (the related DMAS 'Appeals for Clients' page was).
- Not confirmed. medicare.shipUrl and shipPhone — taken from the national SHIP directory, not opened on the state site.
- Published results of independent review. no officially published overturn rate was found.
- State laws that help. Virginia's general prior authorization time limits (Code of Virginia § 38.2-3407.15:2) were not confirmed on an official page and are not listed; the federal directory lists no Consumer Assistance Program for Virginia.