New to helping someone in Rhode Island?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (HealthSource RI, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
Rhode Island law gives you an internal appeal with the insurer first in most cases, then a right to external review through an independent review organization (IRO) approved by the Health Insurance Commissioner.
For steps that work in every state, read these general guides first, then return here for Rhode Island rules:
What is different in Rhode Island?
- HealthSource RI: Rhode Island's state Marketplace at HealthSourceRI.com. Major 2026 carriers: Blue Cross Blue Shield of Rhode Island and Neighborhood Health Plan of Rhode Island.
- Prior authorization: Chapter 27-18.9 — 72-hour urgent / 15-day standard; 2025 pilot bans PA for most in-network primary care orders (not drugs) through Oct. 2028.
- Internal appeals: Same chapter — 72-hour urgent / 30-day non-urgent appeal decisions; qualified reviewer must consult with your provider.
- External review: File within four months of final internal denial; IRO decision within 45 days standard / 72 hours expedited (OHIC); binding on plan.
- Medicaid: MCO appeal first (60 days typical), then EOHHS fair hearing (120 days from MCO decision)—separate from commercial IRO review.
Who is in charge of your plan?
- OHIC: External review oversight, consumer help — ohic.ri.gov. RIREACH helpline: 855-747-3224 · OHIC: 401-270-0101
- U.S. Department of Labor: Many self-funded employer plans.
- EOHHS Appeals Office: Medicaid fair hearings — eohhs.ri.gov · 401-462-2132
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.