Washington Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal (grievance) 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.

Washington requires carriers to provide grievance procedures under RCW 48.43.530 and related rules. You must generally complete internal appeal before certified independent review under RCW 48.43.535.

General walkthrough: Appeals roadmap.

Washington appeal timelines

Carrier grievance (RCW 48.43.530)

Your adverse determination notice must explain how to appeal, deadlines, and OIC contact information. For ongoing treatment, carriers generally cannot reduce or stop benefits without advance notice—see RCW 48.43.535(9).

Federal internal appeal standards (many ACA and group plans)

For many Washington-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 (RCW 48.43.535)

If the carrier exceeds grievance timelines in RCW 48.43.530 without good cause and does not reach a decision, you may proceed to independent review without waiting further.

Expedited simultaneous independent review

When delay would seriously jeopardize life or health, you may request expedited independent review at the same time as an urgent internal grievance in qualifying cases (see RCW 48.43.535 and WAC 284-43-3170).

How to file

1. Read the denial for grievance 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. OIC provides a printable appeals guide (PDF).

Carrier links: Washington 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

Apple Health (Washington Medicaid) uses a separate MCO grievance and administrative hearing process:

• MCO internal appeal: file with your managed care plan when you receive an adverse benefit determination (HCA — file an Apple Health appeal)
• Administrative hearing: after exhausting the MCO process, request a hearing with HCA/OAH—generally within 90 days of the notice you are appealing (HCA appeals portal) · OAH 800-583-8271
• Continuation of benefits: to keep services during appeal, request a hearing within 10 days of the notice mail date when applicable

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial with independent review rights, request certified IRO review within 120 days (OIC — how to appeal).

Next: Washington independent review (OIC / IRO).