Virginia Health Insurance Appeals and Grievances

What is an internal appeal?

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

Virginia requires carriers to provide internal appeals procedures under 14VAC5-216 and Chapter 35.1. You must generally complete internal appeal before SCC external review.

General walkthrough: Appeals roadmap.

Virginia appeal timelines

Carrier internal appeal (14VAC5-216)

Your adverse determination notice must include the carrier's internal appeals procedures, submission deadlines, and Bureau of Insurance contact information. Managed care plans must also list the Office of the Managed Care Ombudsman.

Federal internal appeal standards (many ACA and group plans)

For many Virginia-regulated health benefit plans, federal standards also apply:

• File within 180 days of the adverse benefit determination in most cases
• Pre-service appeals: decision within 30 days
• Post-service appeals: within 60 days
• Urgent appeals: as fast as the medical condition requires, often within 72 hours
• Individual market: often one level of internal appeal; group market: may have two—check your notice

Deemed exhaustion (§ 38.2-3559)

If you file a standard internal appeal and the carrier does not issue a written decision within 30 days (and you did not request or agree to a delay), you may file for external review and are treated as having exhausted internal appeal (§ 38.2-3559).

Expedited external review before exhaustion

You may request expedited external review before exhausting internal appeal when your treating physician certifies that delay would significantly reduce effectiveness of care (including certain cancer treatment denials per § 38.2-3563 and SCC guidance).

How to file

1. Read the denial for appeal instructions and deadlines.
2. Tell your carrier you want to appeal (use the process on your notice—member services, portal, or written grievance address).
3. Submit in writing with member ID, clinical support, and any records your doctor provides.
4. Request expedited review if delay would seriously jeopardize life or health.
5. Keep copies of everything sent and the date sent.

Carrier links: Virginia prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• Insurer's clinical criteria (request in writing if not provided)
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

Virginia Medicaid (Cardinal Care) uses a separate MCO appeal and state fair hearing process:

• MCO internal appeal: file with your managed care plan when you receive an adverse benefit determination (CoverVA — appeals)
• State fair hearing (DMAS): after exhausting the MCO process, request a hearing with DMAS Appeals—often within 120 days of the MCO's final appeal decision; use the AIMS appeals portal or mail/fax/email · 804-371-8488
• Continuation of benefits: to keep services during appeal, request a fair hearing within 10 calendar days of the MCO decision mail date when applicable (12VAC30-120-640)

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial with external review rights, file with the SCC Bureau of Insurance within 120 days (SCC — external review).

Next: Virginia external review (SCC / IRO).