State guide

West Virginia

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

On this page 8

Which plan do you have?
Quick facts for independent review
Who regulates health plans
Independent (external) review
Free help in West Virginia
Medicare and Medicaid in West Virginia
State laws that can help
Sources and what we could not confirm

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

Your employer pays claims itself

West Virginia 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 West Virginia Offices of the Insurance Commissioner. See the at-a-glance box.

Call 1-888-879-9842
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 West Virginia.

Medicaid in West Virginia
Medicare

West Virginia State Health Insurance Assistance Program (SHIP) gives free counseling. Or call 1-800-MEDICARE.

Call 1-877-987-4463 1-800-633-4227

The short version for West Virginia

West Virginia runs its own external review: you send a free application to the Offices of the Insurance Commissioner, which picks a state-certified independent reviewer. The Commissioner's Life and Health Consumer Services unit will also step in on claim denials and act as a go-between with the insurer. State law adds a step therapy exception process and a "gold card" that exempts high-approval doctors from prior authorization. One caution: the state's application says you have 180 days to ask for external review while the state rule says four months, so file within four months to be safe.

At a glance: independent review for plans West Virginia 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: West Virginia Offices of the Insurance Commissioner · 1-888-879-9842 (toll free); (304) 720-8584
Independent review: A state process (External review (independent external review))
Deadline to request it: Official sources disagree: the state's application says within 180 days of the date you were first eligible (normally the date of the insurer's final written denial), while the state rule says within four months of receiving the denial notice. File within four months to be safe.
Cost: None (the application says there is no cost to you)
Decision time: Within 45 days after the request for external review is received (state rule); the Commissioner first takes up to 7 business days to check that the request is complete and eligible; fast track: No more than 72 hours after the expedited request is received (state rule)

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

West Virginia Offices of the Insurance Commissioner
Health insurance sold in West Virginia by insurance companies (fully insured individual and employer plans), plus life, dental, vision and annuity products. It does not handle Medicaid, the West Virginia Children's Health Insurance Program, Medicare, other government programs or employer self-funded plans.

Phone: 1-888-879-9842 (toll free); (304) 720-8584. File a complaint online

Independent (external) review

Process: A state process. Run by West Virginia Offices of the Insurance Commissioner, which selects a state-certified Independent Review Organization (IRO).
Where you file: regulator
How: Complete the External Review Application and send it with the insurer's final denial letter, a copy of your insurance card, your benefit booklet if available and any medical records or provider statements to the Offices of the Insurance Commissioner by email (OICHealthPolicy@wv.gov) or mail (Independent External Review, PO Box 50540, Charleston, WV 25305-0540). For an expedited (urgent) review, call 304-558-3386 or 888-879-9842 before sending paperwork to learn the fastest way to submit.
Which denials qualify: Denials of a covered service because the insurer says it is not medically necessary or is experimental or investigational. Not available for Medicaid, the Children's Health Insurance Program, Medicare, other government programs or employer self-funded plans, or to pursue a malpractice claim.
Appeal to the plan first?: Yes, you must complete the insurer's internal review and receive a final decision, unless you qualify for expedited review, the insurer agrees in writing to skip ahead, or the insurer has not decided your internal review within the required time. If you ask for an expedited external review you must keep pursuing the internal review at the same time.

Official page Request form

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

Free help in West Virginia

West Virginia Offices of the Insurance Commissioner, Life and Health Consumer Services
Trained staff take calls about claim denials, underpayments and network problems on state-regulated health, dental and vision insurance and act as a liaison with the insurance company; the federal Consumer Assistance Program directory lists this office for West Virginia.

Phone: 1-888-879-9842

Medicare and Medicaid in West Virginia

Medicare counseling: West Virginia State Health Insurance Assistance Program (SHIP) · 1-877-987-4463 . Free help with Medicare appeals.
Medicaid agency: West Virginia Bureau for Medical Services (West Virginia Medicaid)
Fair hearing deadline: For a Medicaid managed care plan denial: within 120 days of the date of the plan's appeal decision letter (as stated by the Medicaid health plans; not found on a state page). No deadline is stated on the state Board of Review page. Your notice states the deadline that applies to you.
Good to know: If you are in a Medicaid managed care plan you must finish the plan's appeal before asking for a state fair hearing; the plans say to ask within 13 days of the decision letter if you want ongoing services to continue. Fair hearings are held by the Board of Review (phone 304-352-0805, email OIGBOR@wv.gov), and requests can be made verbally, in writing or online.

Medicaid appeals page How Medicaid appeals work

State laws that can help

Step therapy. Insurers must offer a clear, convenient process to request a step therapy exception, must keep covering a drug for the condition until they decide, and must grant the exception quickly when the required drug would harm you, is expected not to work, was already tried and failed, is not in your best interest, or you are stable on your current drug.

West Virginia Code §33-24-7p
Gold card. A practitioner who averages 30 procedures a year and has a 90 percent final prior approval rate over six months cannot be required to submit prior authorization for that procedure for at least the next six months (drugs, experimental, non-covered and out-of-network services excepted).

West Virginia Code §33-24-7s(k) (2023 Senate Bill 267)
Prior authorization. Insurers must take prior authorization requests through an online portal whose address is printed on your insurance card, accept one prior authorization for an episode of care, and post a full list of everything that needs prior authorization, updated at least quarterly.

West Virginia Code §33-24-7s (2023 Senate Bill 267)
Mental health parity. Health plans must cover inpatient and outpatient substance use disorder treatment at in-network facilities at the same level as other medical services, make network exceptions to get you admitted within 72 hours if no in-network facility is available, and cover medically necessary outpatient drugs for substance use disorder without prior authorization.

West Virginia Code §33-24-7r
External review. Sets the external review process: a request to the Insurance Commissioner, a decision by an independent review organization within 45 days, and within 72 hours in urgent cases.

West Virginia Code of State Rules §114-97 (External Review of Issuers' Adverse Health Insurance Determinations)

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 2026-11-11. Phone numbers and deadlines change; check the official page before you rely on one.

Not confirmed (7)

The deadline to request independent review. the state's own application (dated 2-2016, still the one linked from the External Review page) says 180 days; W. Va. Code R. § 114-97-6.1 (read on the Cornell Legal Information Institute copy) says four months. Not resolved; the shorter period is recommended.
Not confirmed. externalReview.standardDecisionTime and expeditedDecisionTime — from the Cornell Legal Information Institute copy of the state rule; the part of the state's application guide that was read did not reach the decision time.
How to file for independent review. the application and the Life and Health contact block print different local numbers (304-558-3386 on the application; (304) 720-8584 on the web pages); the toll-free number 888-879-9842 appears on both.
How to tell whether the state regulates your plan. no card-based tip was found on the Insurance Commissioner pages loaded.
Not confirmed. medicaid.fairHearingDeadline and medicaid.notes — the 120-day and 13-day figures come from Medicaid health plan member pages (Aetna Better Health of West Virginia, Wellpoint), not from a state page; no deadline for fee-for-service Medicaid hearings was found on the Board of Review page. The health plans say to send managed care hearing requests to the Bureau for Medical Services, Office of Medicaid Managed Care, 350 Capitol Street, Room 251, Charleston, WV 25301-3708.
The Medicare counseling program's web page. taken from the national SHIP directory; the site did not load when tried, so the address is unconfirmed.
The state regulators. online complaint form link copied from the External Review page; the form was not opened.

Sources last checked 11 November 2026. Found a mistake? Report it.