New to helping someone in West 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 (often Highmark, CareSource, or Molina 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 West Virginia-regulated plans, you have an internal grievance with the issuer first, then a right to independent external review through an OIC-certified IRO under W. Va. Code § 33-16H-2 and CSR 114-97-6.
For steps that work in every state, read these general guides first, then return here for West Virginia rules:
What is different in West Virginia?
- HealthCare.gov: West Virginia uses the federal Marketplace at HealthCare.gov. Major carriers include Highmark Blue Cross Blue Shield West Virginia, CareSource, and Molina Healthcare (availability varies by county).
- Prior authorization: W. Va. Code § 33-24-7s (SB 267)—electronic portal required; 5 business days standard / 2 business days urgent; episode-of-care PA; gold carding (30 procedures/year, 90% approval); 90-day cross-plan PA portability.
- Internal appeals: CSR 114-96 grievance process; federal standards often apply—180 days to file; 30-day deemed exhaustion if no written grievance decision (CSR 114-97-5).
- External review: File within 4 months of adverse/final determination; IRO decision within 45 days standard / 72 hours expedited; binding on issuer.
- Medicaid: MCO internal appeal first, then BMS state fair hearing—120 days after MCO final decision—not commercial IRO review.
Who is in charge of your plan?
- W.Va. Offices of the Insurance Commissioner (OIC): External review, regulated commercial plans — External review. Consumer Services: 888-879-9842 · OICHealthPolicy@wv.gov
- U.S. Department of Labor / HHS: Many self-funded ERISA plans.
- Bureau for Medical Services (BMS): Medicaid/Mountain Health Promise appeals — bms.wv.gov · 304-558-1700
- CMS / SHIP: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.