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Did you receive a health insurance denial? Don't panic.
You may have the right to dispute the company's decision.

Deadlines matter. First, file an internal appeal directly with your insurance company. Appeals should be submitted in writing to the insurance company unless you are waiting for authorization on urgent clinical care. Urgent appeals can be submitted verbally to the company as needed.

The denial letter from the insurance company must explain the denial decision, contain your appeal rights, and appeal time frame.

Review the reason for the denial thoroughly to determine if you need to gather more supporting evidence, clarify information from your doctor or care team, or whether you need to request an exception based on the circumstances in your appeal.

If the denial issue is complex, contact the Oregon Division of Financial Regulation's Consumer Advocacy Unit to speak with an insurance advocate. Our advocates can provide general information and guidance about your situation, and they can advise you on how to file a complaint with the division if needed.

Division of Financial Regulation Consumer Advocates do not approve medical services or make decisions about medical necessity. The division regulates insurance companies and insurance agents according to the provisions of a consumer's health insurance policy contract and in compliance with insurance regulations.

After you have exhausted your internal appeals with the insurance company and if your denial is based on a clinical decision, you may qualify for an external review appeal by an independent review organization. Check the appeal rights included with your denial notice to confirm if you have external appeal rights.

Only an independent review organization can advise you on whether you qualify for an external appeal review. An independent review organization is a neutral external medical expert that is not affiliated with your insurer and is appointed by the Division of Financial Regulation to only review your case for medical necessity.

You generally have 180 days from the date of the appeal denial to file your request for an external appeal review unless otherwise specified in the appeal rights section within the denial issued by your insurance company.

If a standard wait time threatens your life or health, you can request an expedited external appeal review by your insurance company. To start an external appeal review, submit your request directly to your insurance company. It will notify the Division of Financial Regulation, which will then assign an independent reviewer to your case.

Exercise your consumer rights. Access your right to the appeal process.

For more information, review our consumer guide to health insurance appeals or contact the division's consumer advocacy team for help.

Call 888-877-4894 (toll-free) or visit dfr.oregon.gov and go to the "If your claim was denied" page.

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Oregon Division of Financial Regulation
Visit: dfr.oregon.gov
Call: 888-877-4894 (toll-free)
Email: DFR.InsuranceHelp@dcbs.oregon.gov