State guide
Washington
Pick the kind of plan you have to see who to call first. Washington 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
Washington 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 Washington State Office of the Insurance Commissioner (OIC). 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 Washington.
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Medicare
Statewide Health Insurance Benefits Advisors (SHIBA) gives free counseling. Or call 1-800-MEDICARE.
The short version for Washington
Washington's Office of the Insurance Commissioner (OIC) gives appeal-writers more than most states: sample appeal letters, and a public search of independent review decisions since 2016 showing the insurer, diagnosis, treatment and the reviewer's reasoning. You ask your insurer, not the state, for the independent review; it costs you nothing and the insurer must keep covering ongoing treatment during the review if you ask. Washington also has fast prior authorization deadlines and a drug exception rule under which a request that is not answered in time is automatically approved.
At a glance: independent review for plans Washington regulates
- Main regulator
- Washington State Office of the Insurance Commissioner (OIC) · 800-562-6900
- Independent review
- A state process (Independent review by an independent review organization (IRO); state rules also call it external review)
- Cost
- None. State rule requires the insurer to provide the review without any cost to you or your provider.
- Decision time
- Within 15 days after the reviewer receives the necessary information or 20 days after it receives the referral, whichever is earlier (up to 25 days in exceptional cases); fast track: Within 72 hours after the request for expedited review is received
Who regulates health plans
The Insurance Commissioner's chart sorts coverage by who regulates it: individual plans and fully insured group plans follow Washington state law; self-funded group plans follow federal law. The office does not give a card-based test; it says to double check with your human resources department to find out which type of plan your employer has.
- Washington State Office of the Insurance Commissioner (OIC)
Individual health plans bought from an insurance company, agent or Washington Healthplanfinder, and fully insured group plans bought through work or an association. It does not regulate self-funded employer plans, Medicare, or Apple Health (Washington Medicaid).
Phone: 800-562-6900. File a complaint online
Independent (external) review
- Process
- A state process. Run by Your insurer sends the case to a state-certified independent review organization chosen in rotation from the Insurance Commissioner's registry; the Office of the Insurance Commissioner certifies the reviewers and collects every decision.
- Where you file
- insurer
- How
- Ask your health insurer for an independent review after it denies your appeal; the insurer's decision letters must explain how. The insurer must tell you which review organization was assigned within one day, and you then have five business days to send that organization extra information in writing. If your insurer does not cooperate, call the Insurance Commissioner's consumer advocates at 800-562-6900.
- Which denials qualify
- Denials based on medical necessity, appropriateness, health care setting, level of care, or a finding that the service is not effective or not justified under evidence-based medical criteria (the state's decision search also shows experimental or investigational denials and contract coverage disputes). There is no minimum dollar amount.
- Appeal to the plan first?
- Yes, unless the insurer waives it, the insurer misses its own appeal deadlines without good cause, or the review is requested under the expedited or concurrent review rules. If the insurer changes, reduces or stops ongoing treatment, you can ask for independent review of that decision and the insurer must continue the service until the reviewer decides if you request it.
Free help in Washington
- Office of the Insurance Commissioner, Consumer Advocacy
Consumer advocates answer questions about appeals and investigate complaints against state-regulated health insurers (8:30 a.m. to 4:30 p.m. weekdays); the federal directory lists no separate Consumer Assistance Program for Washington.
Phone: 800-562-6900
Medicare and Medicaid in Washington
- Medicare counseling
- Statewide Health Insurance Benefits Advisors (SHIBA) · 1-800-562-6900 . Free help with Medicare appeals.
- Medicaid agency
- Washington State Health Care Authority (HCA), Apple Health (Medicaid)
- Fair hearing deadline
- 90 days from the date of the decision for agency decisions; for a managed care plan denial, 120 calendar days from the date you receive the plan's notice resolving your appeal. Your notice states the deadline that applies to you.
- Good to know
- If you are in an Apple Health managed care plan you must finish the plan's appeal (one level) before asking for a hearing. To keep previously authorized services going during the hearing, ask for the hearing and for continued services within 10 days of the plan's appeal decision notice; you may have to pay for those services if you lose. Hearing requests can be made by phone to the Office of Administrative Hearings at 1-800-583-8271 or the Health Care Authority at 1-800-562-3022. After a lost hearing, managed care enrollees can also request an independent review.
State laws that can help
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Prior authorization. For plans issued or renewed since January 1, 2024, insurers must decide electronic prior authorization requests within three calendar days (one calendar day if expedited) and paper or phone requests within five calendar days (two if expedited).
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Step therapy. Plans that use step therapy or other drug restrictions must offer a clear, posted exception process; the Insurance Commissioner says the insurer must answer within three days (one day if urgent) and that a request not answered in time is automatically approved.
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Surprise billing. Out-of-network providers and facilities may not balance bill you for emergency services, non-emergency care by out-of-network providers at certain in-network facilities, or air ambulance services.
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External review. Guarantees independent review by a state-certified organization at no cost to you, with a 72-hour decision in urgent cases, and requires the insurer to keep providing a service it is cutting off while the review is pending if you ask.
Sources and what we could not confirm
- OIC: How to appeal a health insurance denial
- OIC: Common reasons for a denial and examples of appeal letters
- OIC: Look up an independent review decision
- OIC: Independent review organization process
- OIC: Identify your type of insurance coverage
- OIC: File a complaint or check your complaint status
- OIC: Getting your health plan to cover your prescription drug
- RCW 48.43.535, Independent review of health care disputes
- WAC 284-43A-140, External review of adverse benefit determinations
- WAC 284-43A-070, Independent review process (time frames)
- CMS: State External Appeals Review Processes
- CMS: Consumer Assistance Program (Washington listed as having no program)
- Health Care Authority: Requesting an administrative hearing
- Health Care Authority: WAC 182-526-0200, Enrollee appeals of a managed care organization action
- Health Care Authority: Appeal rights fact sheet (PDF)
- OIC Technical Assistance Advisory 2023-04 (prior authorization timelines)
- SHIP National Technical Assistance Center: Washington
Not confirmed (6)
- The deadline to request independent review. no deadline for requesting independent review was found on the Insurance Commissioner's web pages or in the rule sections read (WAC 284-43A-140, RCW 48.43.535); the insurer's final decision letter states it. Left null instead of guessing.
- The independent review request form. the state publishes no consumer request form; the request goes through the insurer.
- Published results of independent review. the decision search shows outcomes case by case, but no officially published overturn rate was found.
- Which denials qualify for independent review. experimental or investigational denials and contract coverage disputes appear as review reasons in the state's decision search (per earlier site research), not in the rule text read today.
- The Medicare counseling program's web page. taken from the national SHIP directory; not opened on the state site.
- Not confirmed. stateLaws (step-therapy) — the response times and automatic approval are from the Insurance Commissioner's consumer page on drug exceptions; only the first subsections of RCW 48.43.420 were read.