New to helping someone in Washington?
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 (Premera, Regence, Kaiser, CHPW, and others).
- 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 (Washington Healthplanfinder, job-based, Apple Health/Medicaid, Medicare) and write down the appeal deadline from the letter.
For many Washington-regulated plans, you have a carrier grievance (internal appeal) first, then a right to certified independent review through an OIC-certified IRO under RCW 48.43.535 and WAC 284-43A-070.
For steps that work in every state, read these general guides first, then return here for Washington rules:
What is different in Washington?
- Washington Healthplanfinder: State-based Marketplace at wahealthplanfinder.org. Major 2026 Exchange carriers include Premera, Regence, Kaiser, LifeWise, CHPW, Molina, Coordinated Care, BridgeSpan, and others (availability varies by county).
- Prior authorization: RCW 48.43.830 (HB 1357)—electronic PA often 3 calendar days standard / 1 day expedited; non-electronic 5 / 2 calendar days; full ePA compliance by January 1, 2027.
- Internal appeals: Carrier grievance under RCW 48.43.530; federal standards often apply—180 days to file; 30/60-day decisions; deemed exhaustion if the carrier misses grievance timelines without good cause.
- Independent review (IRO): Free to you—file within 120 days of final adverse determination; IRO decision within 15–20 days standard or 72 hours expedited; binding on the carrier.
- Apple Health (Medicaid): MCO grievance first, then HCA/OAH administrative hearing—often 90 days from the notice—not commercial IRO review.
Who is in charge of your plan?
- OIC (Office of the Insurance Commissioner): Independent review, regulated commercial plans — Appealing a denial. Consumer Advocacy: 800-562-6900
- U.S. Department of Labor / HHS: Many self-funded ERISA plans.
- HCA / Apple Health: Medicaid appeals — HCA appeals (AIMS portal) · 804-371-8488 · OAH 800-583-8271
- CMS / SHIBA: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.