What is an internal appeal?
An internal appeal (grievance) asks the health issuer 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.
Issuers must provide internal grievance procedures under W. Va. Code § 33-16H-2 and CSR 114-96. You must generally complete internal grievance before OIC external review.
General walkthrough: Appeals roadmap.
West Virginia appeal timelines
Issuer internal grievance (CSR 114-96)
Your adverse determination notice must explain how to file a grievance, deadlines, and your right to external review. Issuers must make external review available for adverse determinations under § 33-16H-2.
Federal internal appeal standards (many ACA and group plans)
For many West 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 (often 10 business days for WV pre-service per carrier manuals)
- Post-service appeals: within 60 days (often 30 calendar days for WV post-service)
- Urgent appeals: as fast as the medical condition requires, often within 72 hours
Deemed exhaustion (CSR 114-97-5)
If you file a grievance and the issuer does not provide a written decision within 30 days (and you did not request or agree to a delay), you are deemed to have exhausted internal grievance and may request external review.
Expedited simultaneous external review
You may file an expedited external review at the same time as an expedited internal grievance when medically appropriate (CSR 114-97-5.3).
Ongoing treatment protections
Issuers generally cannot reduce or stop ongoing covered treatment without advance notice; in some cases you may seek IRO review when benefits change mid-treatment—see your notice and OIC guidance.
How to file
- Read the denial for grievance instructions and deadlines.
- Tell your issuer you want to appeal (use the process on your notice—member services, portal, or written grievance address).
- Submit in writing with member ID, clinical support, and any records your doctor provides.
- Request expedited review if delay would seriously jeopardize life or health.
- Keep copies of everything sent and the date sent.
Carrier links: West 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
Medicaid appeals
West Virginia Medicaid / Mountain Health Promise uses a separate MCO grievance and state fair hearing process:
- MCO internal appeal: file within 60 calendar days of the Notice of Action (check your MCO materials)
- State fair hearing (BMS): after exhausting the MCO process, request within 120 calendar days of the MCO appeal decision (Bureau for Medical Services) · mail to 350 Capitol Street, Room 251, Charleston, WV 25301-3708
- BMS generally decides within 90 days of the fair hearing request
After internal appeal
If you receive a final adverse determination with external review rights, file with the OIC within 4 months (OIC — external review).