New to helping someone in D.C.?
Start with three things from the patient or family:
- Insurance card — shows the carrier and plan name
- Denial letter or explanation of benefits (EOB) — lists appeal rights and deadlines
- Summary of Benefits and Coverage (SBC) — if available
Your first job is to learn what kind of plan this is (DC Health Link, job-based, Medicaid, Medicare) and what deadline the letter gives you. D.C. plans use terms like adverse benefit determination, internal appeal, and external review through the Health Care Ombudsman.
For steps that work in every state, use these general guides first, then return here for District rules:
What is different in the District?
- DC Health Link: Individual and small-group health coverage in D.C. is sold through DC Health Link (not a separate HealthCare.gov state). DISB certifies carriers; major Marketplace issuers include CareFirst BCBS, Kaiser Permanente, and UnitedHealthcare.
- Prior authorization reform (2024): Non-urgent PA often within 3 business days (electronic) or 5 business days (mail/phone/fax); urgent within 24 hours; missed deadlines can mean services are deemed approved (D.C. Code Title 31, Ch. 38F (§§ 31-3875.01 et seq.)).
- Internal appeals: Request internal review within 180 days of an adverse benefit determination; carrier often has 30 days (prospective) or 60 days (retrospective) to decide (D.C. Code § 44-301.06).
- External review: After a final internal denial, file with the Office of Health Care Ombudsman and Bill of Rights within 4 months; IRO decision often within 45 calendar days (72 hours expedited) (§ 44-301.07).
- Medicaid (Alliance / managed care): MCO grievance, then DHCF fair hearing—see DHCF member materials.
Who is in charge of your plan?
- DISB (Department of Insurance, Securities and Banking): Fully insured health plans, consumer complaints — disb.dc.gov. Consumer line: 202-727-8000.
- Office of Health Care Ombudsman: External review intake — dhcf.dc.gov — Ombudsman.
- U.S. Department of Labor: Many self-funded employer plans.
- DHCF: Medicaid and Alliance fair hearings — dhcf.dc.gov — grievances/appeals.
- CMS: Medicare and Medicare Advantage.
For complaints after appeals, see Regulator complaints.