What is an internal appeal?
An internal appeal asks the insurance company to reconsider its own denial. The same company (or a contractor it hires) reviews the case again—often with a doctor who was not involved in the first decision.
This is different from external review, where IDOI assigns an independent review organization (IRO) that does not work for the insurer. Illinois law generally requires you to complete internal appeals first, with limited exceptions.
General walkthrough: Appeals roadmap. Illinois specifics below.
Illinois appeal timelines
The Managed Care Reform and Patient Rights Act (215 ILCS 134) sets how HMOs and similar health care plans must handle appeals of coverage decisions (Section 45).
Urgent appeals (risk of serious harm)
When denying ongoing treatment or a referral could significantly increase health risk, the plan must:
- Accept the appeal orally or in writing
- Within 24 hours of filing, tell you what information it still needs
- Decide within 24 hours after it receives that information
- Notify you, your doctor, and the treating provider orally, then in writing
Standard appeals (most other services)
- Within 3 business days of filing, the plan must list information it still needs
- Decision within 15 business days after it receives that information
- Oral notice of the decision, then written notice with reasons and clinical criteria
Who can file
The enrollee, a designee or guardian, the primary care physician, or the treating provider may file. A clinical peer (a qualified health professional) must review medical appeals; the reviewer cannot have been involved in the original denial.
Written denial must explain external review
If the internal appeal is denied, the written notice must explain how to request external independent review under 215 ILCS 180.
How to file
- Read the denial letter for the appeal address, fax, portal, or phone number and the deadline.
- Request the plan's appeal form if one exists, but Illinois allows oral appeals for urgent cases.
- State clearly that you are appealing an adverse determination and want a clinical peer review.
- Send supporting records the same day if possible—delays in sending records can delay the clock.
- Keep proof of submission (fax confirmation, portal screenshot, certified mail receipt).
Consumer step-by-step (including exhaustion rules): coveragerights.org — Illinois.
IDOI consumer help: 866-445-5364 — IDOI consumers.
Evidence that helps
- Letter from the treating doctor explaining medical necessity and why alternatives fail
- Recent clinical notes, test results, and treatment history
- Peer-reviewed guidelines or specialty society recommendations when relevant
- Prior approvals for the same service on the same plan
Medicaid appeals
For HealthChoice Illinoismanaged care, appeal the MCO's adverse action first using the plan's member handbook. If you disagree with the MCO decision, you may request a fair hearing with HFS. That path is separate from IDOI commercial external review.
After internal appeal
If you receive a final adverse determination on a medical-necessity-type issue, you may qualify for IDOI external review. File within 4 months of the final denial in most cases.
Illinois external review (IDOI)
Self-funded ERISA plans may use federal external review instead—see Self-funded ERISA plans.