New Hampshire Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal asks the health carrier to reconsider a claim denial or adverse determination under RSA 420-J:5 (Grievance Procedures).

This is different from external review, where the New Hampshire Insurance Department assigns an independent review organization (IRO) after internal review is complete (with limited urgent exceptions).

General walkthrough: Appeals roadmap.

New Hampshire appeal timelines

Filing deadline

• Appeal within 180 days after receiving notice of a claim denial (RSA 420-J:5, I(c))
• Full and fair review by people who did not make the initial denial; access to relevant records on request (RSA 420-J:5, I)
• Medical necessity appeals reviewed by appropriate specialists (RSA 420-J:5, I–II)

Decision deadlines

• Standard appeals: no more than 30 days after the carrier receives your appeal (RSA 420-J:5, IV(a))
• Plans with two mandatory levels: first level within 15 days, second within 30 days from initial filing (RSA 420-J:5, V(e))
• Expedited appeals: decision within 72 hours when urgent harm is at risk; ongoing urgent services may continue pending decision (RSA 420-J:5, III–IV(b))

If the carrier is late

If the carrier misses required appeal time frames, it must promptly tell you about your right to external review (RSA 420-J:5, VI(g)). Late decisions can also satisfy exhaustion under RSA 420-J:5-a, I(b).

How to file

1. Read the denial for appeal instructions and deadlines.
2. Submit in writing when possible—urgent appeals may use phone or fax per plan procedures.
3. Include clinical support and request copies of records the carrier used.
4. Request expedited review if delay would cause serious harm.
5. Keep copies of everything sent and the date sent.

Carrier links: New Hampshire prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• All records the carrier relied on—or should have considered
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

New Hampshire Medicaid managed care requires an MCO appeal before a state fair hearing:

• MCO appeal: typically 60 calendar days from the notice of action
• MCO must resolve standard appeals within 30 days (extensions possible with notice)
• State fair hearing: written request to DHHS within 120 calendar days of the MCO resolution notice (He-W 506.09) — contact DHHS at 800-852-3345, ext. 4292

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial, request external review from the NH Insurance Department within 180 days (RSA 420-J:5-a).

Next: New Hampshire external review.