Rhode Island Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal asks the health plan to reconsider an adverse benefit determination—when the plan denies PA, reduces payment, or says care is not medically necessary or not covered.

This is different from external review, where an IRO approved by the Health Insurance Commissioner reviews the case after internal review is complete.

General walkthrough: Appeals roadmap.

Rhode Island appeal timelines

Chapter 27-18.9 (Benefit Determination Act)

Rhode Island requires insurers and review agents to maintain internal appeal procedures consistent with applicable federal law and Chapter 27-18.9. For most modern health plans, that includes:

• File within 180 days of the adverse benefit determination in many cases (federal internal claims rules)
• Urgent appeals: decision within 72 hours
• Non-urgent appeals: decision within 30 calendar days
• Pre-service appeals: often aligned with 30-day federal norms
• Post-service appeals: often within 60 days under federal rules

Qualified reviewer requirement

Insurers may not uphold a non-administrative appeal denial unless an appropriately qualified provider has had direct communicationwith the patient's treating provider (unless the treating provider refuses).

Final adverse benefit determination

After the final internal level, your notice must explain how to request external review within at least four months (§ 27-18.9-8).

How to file

1. Read the denial for appeal instructions and deadlines.
2. Submit in writing when possible—include member ID, claim number, and clinical support.
3. Request expedited review if delay would cause serious harm.
4. Keep copies of everything sent and the date sent.

Carrier links: Rhode Island prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• Insurer's clinical criteria (you have a right to request them)
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

Medicaid managed care requires an MCO appeal before a state fair hearing in most cases:

• MCO appeal: typically within 60 calendar days of the denial notice; plan must decide within about 30 days (extensions possible with notice)
• State fair hearing (EOHHS): request within 120 calendar days of the MCO appeal decision (210-RICR-10-05-2.4) · 401-462-2132 · OHHS.AppealsOffice@eohhs.ri.gov

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial, request external review within four months (OHIC — consumer protection).

Next: Rhode Island external review.