New to helping someone in Virginia?
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 (Anthem, Kaiser, Optima, Molina, and others on HealthCare.gov).
- 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 (HealthCare.gov, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
For many Virginia-regulated plans, you have an internal appeal with the carrier first, then a right to independent external review through the SCC Bureau of Insurance under Chapter 35.1 (14VAC5-216).
For steps that work in every state, read these general guides first, then return here for Virginia rules:
What is different in Virginia?
- HealthCare.gov: Virginia uses the federal Marketplace at HealthCare.gov. Major 2026 individual-market carriers include Anthem, Kaiser Permanente Mid-Atlantic, Optima Health, Oscar, Molina, and others (availability varies by county).
- Prior authorization: Prescription drug PA under § 38.2-3407.15:2 — 24 hours urgent / 2 business days standard; electronic PA portal required by July 1, 2025; broader medical-service PA rules in § 38.2-3407.15:8 effective January 1, 2027.
- Internal appeals: Carrier grievance under 14VAC5-216; federal standards often apply — 180 days to file; 30/60-day decisions; 72-hour urgent; deemed exhaustion if no written decision within 30 days without agreed delay (§ 38.2-3559).
- External review: Free SCC Bureau review — file within 120 days of your external-review rights notice; IRO decision within 45 days standard or 72 hours / 6 business days expedited; binding on the carrier.
- Medicaid: MCO internal appeal first, then DMAS state fair hearing (often 120 days after MCO final action)—not commercial SCC external review.
Who is in charge of your plan?
- SCC Bureau of Insurance: External review, regulated commercial plans — External review. 877-310-6560 · externalreview@scc.virginia.gov
- Office of the Managed Care Ombudsman: Help with managed care plans — Managed care ombudsman
- U.S. Department of Labor / HHS: Many self-funded ERISA plans.
- DMAS: Medicaid appeals — DMAS appeals (AIMS portal) · 804-371-8488
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.