What is an internal appeal?
An internal appeal—often called a grievanceunder your plan's internal claims process—asks the insurance company to reconsider its adverse determination about coverage or payment.
This is different from external review, where the Louisiana Department of Insurance assigns an independent review organization (IRO) after internal appeal is complete (with limited exceptions).
General walkthrough: Appeals roadmap. Louisiana specifics below.
Louisiana appeal timelines
RS 22:2401 requires health issuers to maintain an internal claims appeal process that meets federal standards and Louisiana notice requirements (read statute):
- Written notice of internal and external appeal rights in culturally appropriate language
- Free access to all documents relevant to the claim and the right to submit additional evidence
- Continued coverage during appeal when required by federal law or your policy
- LDI Office of Consumer Advocacy may help you navigate appeals
30-day exhaustion rule
Under RS 22:2433, if you file an internal grievance and the issuer does not issue a written decision within 30 days (and you did not agree to a delay), you may file for external review and are treated as having exhausted internal appeals (RS 22:2433(B)(1)(a)(ii)).
Urgent appeals
When delay could seriously harm health, your denial notice should explain expedited options. Louisiana allows simultaneous expedited internal and external review in some cases; the assigned IRO may require internal review to finish first (RS 22:2433).
Utilization review appeals
PA and UR denials under RS 22:1260.46 must include appeal rights. Peer review may be available when a provider disputes a UR denial.
How to file
- Read the adverse determination letter for the appeal address, fax, portal, phone, and deadline.
- Submit to the issuer using its grievance/appeal form or a clear written request.
- Request expedited review if hospitalized or at serious health risk.
- Ask for all claim files—Louisiana law requires the issuer to provide relevant documents free of charge.
- Keep proof of submission and the date filed (important for the 30-day rule).
LDI consumer help: 800-259-5300 — ldi.la.gov — health insurance · Understanding your healthcare rights (PDF)
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
Healthy Louisiana appeals
Medicaid members appeal with their MCOfirst (Humana Healthy Horizons, Louisiana Healthcare Connections, Aetna Better Health, UnitedHealthcare Community Plan, etc.). If you disagree with the MCO's appeal decision, request a state fair hearing within 120 days (often via the Division of Administrative Law).
LDH — How to appeal Medicaid · DAL — Health & Hospitals hearings
To keep services during appeal in some cases, file within 10 days of the denial and request continuation of benefits on the hearing form.
After internal appeal
If you receive a final adverse determination, request external review with your health insurance issuer within 4 months (RS 22:2436). The issuer notifies LDI, which assigns an IRO.
Louisiana external review (LDI / IRO)
Self-funded ERISA plans may use federal external review instead — see Self-funded ERISA plans.