What is an internal appeal?
An internal appeal asks the insurance company to reconsider its own adverse determination (often called an adverse benefit determinationor ABD). The plan or its utilization review agent reviews the case again under Kentucky's internal appeals process.
This is different from external review, where a DOI-certified independent review entity (IRE) decides the case after internal appeal is complete.
General walkthrough: Appeals roadmap. Kentucky specifics below.
Kentucky appeal timelines
KRS 304.17A-617 requires every insurer to maintain an internal appeals process (read statute):
Standard internal appeal
- Decision within 30 days of receiving the appeal request
- You, an authorized person, or a provider (with permission) may file
Expedited internal appeal
Decision within 3 business days when:
- The covered person is hospitalized, or
- The treating provider believes a standard timeline would seriously jeopardize health, pregnancy, bodily function, or organ function
Second level of internal review
Some plans offer two internal levels. Kentucky law gives you extra rights at the second level (records access, in-person appearance, physician reviewer). You may also waive the second level in writing and move to external review after the first level (304.17A-617).
What the final denial must say
When internal appeal upholds a denial, the letter should explain how to request external review and include filing instructions (806 KAR 17:290).
How to file
- Read the adverse determination letter for appeal address, fax, portal, phone, and deadline.
- Submit to the insurer(not DOI first) using the plan's form or a clear written appeal.
- State that you want an internal appeal of the adverse determination and request expedited review if urgent.
- Attach clinical records the same day if possible.
- Keep proof of submission and the date you filed.
DOI Consumer Protection: 800-595-6053 — insurance.ky.gov.
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 when relevant
- Prior approvals for the same service on the same plan
KanCare appeals
KanCare members appeal an MCO adverse actionwith their managed care plan first (deadlines on the MCO notice). If you disagree with the MCO's appeal decision, you may request a fair hearing with the Department for Medicaid Services.
DMS — How to request a hearing (PDF) · kynect — benefits & Medicaid
To keep services during appeal in some cases, follow deadlines on your denial notice (often 10 days to request continuation of benefits).
After internal appeal
If internal appeal upholds the denial, submit a request for external review to your insurer within 60 days of that notice, with written consent for the IRE to obtain medical records (KRS 304.17A-623).
Kentucky external review (IRE)
Self-funded ERISA plans may use federal external review instead — see Self-funded ERISA plans.