Review & Appeals
Table 4: Review & Appeals |
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Internal UM Appeal Levels |
Notice Of Appeal Rights in Adverse Determination Required |
Timeframe Standard Appeal |
Timeframe Expedited Appeal |
Extension Option |
Final Notification Requirement(s) |
|
Alabama |
Yes |
30 days |
48 hours |
Yes | ||
Alaska |
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Arizona |
2 |
Yes |
30 days (Informal Appeal or Formal Appeal); 60 days (Formal Appeal for Retrospective Decision) |
1 day |
Yes |
|
Arkansas |
|
|
|
|
||
California |
Yes |
30 days |
3 days |
|||
Colorado |
|
Yes |
30 days |
72 hours |
Yes |
Yes |
Connecticut |
1 |
Yes |
30 days (Prospective or Concurrent Reviews); 60 days (Retrospective Reviews) |
72 hours |
Yes |
|
Delaware |
Yes |
30 days (For requests for referrals or determinations concerning benefit coverage); 45 days (For all other instances) |
72 hours |
Yes |
Yes |
|
District of Columbia |
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Florida |
||||||
Georgia |
1 |
Yes |
60 days |
Yes |
||
Guam |
||||||
Hawaii |
1 |
Yes |
60 days |
72 hours |
||
Idaho |
Yes |
2 days (For prior authorization of non-emergency service) |
||||
Illinois |
Yes |
30 days (For Prospective or Concurrent Reviews); 60 days (For Retrospective Reviews) |
48 hours |
Yes |
||
Indiana |
Yes |
30 days |
48 hours |
Yes |
||
Iowa |
|
|
||||
Kansas |
2 |
Yes |
15 days (Second Level Prospective Review); 30 days (Second Level Retrospective Review) |
72 hours (Second Level Review involving Emergency Situation) |
Yes |
|
Kentucky |
Yes |
30 days |
3 days |
No |
Yes |
|
Louisiana |
2 |
Yes |
30 days |
Yes |
||
Maine |
2 |
Yes |
30 days |
72 hours |
Yes |
Yes |
Maryland |
2 |
Yes |
30 days; 45 days (Retrospective Review) |
24 hours |
Yes |
|
Massachusetts |
1 |
Yes |
1 day |
|
|
Yes |
Michigan |
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Minnesota |
2 |
Yes |
30 days |
72 hours |
Yes |
|
Mississippi |
1 |
Yes |
60 days |
1 day |
Yes |
|
Missouri |
2 |
Yes |
15 days |
72 hours |
Yes |
|
Montana |
1 |
Yes |
15 days (Prospective Reviews); 30 days (Retrospective Reviews) |
72 hours |
Yes |
|
Nebraska |
1 |
Yes |
15 days |
72 hours |
Yes |
|
Nevada |
Yes |
30 days |
72 hours |
Yes |
||
New Hampshire |
Yes |
15 days |
72 hours |
|||
New Jersey |
2 |
Yes |
10 days (For First Level Review); 20 days (For Second Level Review) |
72 hours |
Yes |
|
New Mexico |
2 |
Yes |
20 days; 40 days (For Post-Service Reviews) |
72 hours |
Yes |
Yes |
New York |
Yes |
60 days |
2 working days |
Yes |
||
North Carolina |
2 |
Yes |
30 days |
4 days |
Yes |
|
North Dakota |
||||||
Ohio |
Yes |
30 days |
7 days |
Yes |
||
Oklahoma |
||||||
Oregon |
2 |
30 days |
||||
Pennsylvania |
2 |
Yes |
30 days (For First Level Reviews); 45 days (For Second Level Reviews) |
48 hours |
Yes |
|
Puerto Rico |
2 |
Yes |
15 days (For Prospective Reviews); 30 days (Retrospective Reviews) |
48 hours |
Yes | |
Rhode Island |
|
Yes |
30 days (For Pre-Service Claim Reviews or Non-Administrative Reviews); 60 days (Post-Service Claim Reviews); 30 days (For Drug Coverage Reviews) |
72 hours |
|
|
South Carolina |
Yes |
30 days |
2 days |
Yes |
||
South Dakota |
Yes |
15 days (For Prospective Reviews); 30 days (For Retrospective Reviews) |
24 hours |
Yes |
Yes |
|
Tennessee |
2 |
Yes |
30 days (For Prospective Reviews); 60 days (For Retrospective Reviews) |
48 hours |
Yes |
|
Texas |
|
Yes |
30 days |
1 day |
No |
Yes |
Utah |
||||||
Vermont |
2 |
Yes |
30 days (For Prospective Reviews); 60 days (For Retrospective Reviews) |
24 hours (For Concurrent Reviews); 72 hours (For Retrospective Reviews) |
Yes |
|
Virgin Islands |
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Virginia |
2 |
Yes |
30 days (For Prospective Services/Health Carriers); 60 days (For Retrospective Services/Health Carriers); 2 days (For Private Review Agents) |
72 hours (For Health Carriers) |
Yes |
|
Washington |
2 |
Yes |
14 days; 20 days (For Experimental or Investigational Treatment) |
72 hours |
Yes |
Yes |
West Virginia |
Yes |
15 days (For Prospective Reviews); 30 days (For Retrospective Reviews) |
72 hours |
Yes |
Yes |
|
Wisconsin |
|
|
|
|
||
Wyoming |
Yes |
45 days |
72 hours |
Yes |
||