How appeals work in D.C.
When a D.C.-regulated carrier denies or reduces coverage, you receive an adverse benefit determination notice. Carriers must maintain an internal appeals process under D.C. Code § 44-301.06 and the broader grievance system in § 44-301.03.
You appeal with the carrier first. If you receive a final denial, you may request external review through the Health Care Ombudsman.
Universal how-to: Appeals roadmap and Building a strong appeal packet.
The usual steps
- Adverse benefit determination — read denial reasons and appeal rights on the notice.
- Internal appeal — request review within 180 days of the notice (§ 44-301.06(a)(2)). You may submit evidence and ask for your file.
- Carrier acknowledgement — often within 10 business days of receiving your appeal.
- Written decision — includes external review rights and forms if the appeal is denied.
- External review — see D.C. external review.
For mental health appeals, D.C. law has special confidentiality rules—a treating clinician may authorize review by an independent mental health professional without disclosing records to the insurer (§ 44-301.06(b)(6)).
How long the carrier has to answer
After the carrier has all necessary documentation:
- 24 hours — appeals from urgent or emergency medical condition denials
- 30 calendar days — most prospective (pre-service) appeals
- 60 calendar days — retrospective (post-service) appeals (§ 44-301.06(f))
You may request continued coverage at prior benefit levels while the appeal is pending (§ 44-301.06(e)).
If the carrier is late
If the insurer misses internal appeal deadlines or procedures—or further internal review would require disclosing confidential mental health information you do not want shared—you may be relieved of exhausting internal review and may proceed directly to external review (§ 44-301.06(i); § 44-301.03(g)).
Missed PA deadlines under Chapter 38F can also deem services approved—see D.C. prior authorization law.
What comes next?
After a final internal denial, file external review with the Office of Health Care Ombudsman and Bill of Rights within 4 months (DHCF — external appeal; § 44-301.07).
Key takeaway
File the internal appeal within 180 days, track the 30- or 60-day answer window (or 24 hours if urgent), and read the final letter for Ombudsman external review rights. You have 4 months from that final decision to start external review.