Health insurance or Medicaid said no in Virginia? Deadlines and free help

In Virginia, your health plan is regulated by Virginia State Corporation Commission, Bureau of Insurance, if it is a state-regulated plan.

Virginia runs its own independent review of denials: External Review. You generally have 120 days to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Virginia Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Virginia's Insurance Marketplace) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Virginia?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
120 days
Hearing deadline
30 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Virginia's Insurance Marketplace
90 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

State external review covers fully insured plans issued in Virginia, and self-insured employer plans only if the plan opted in to Virginia's process. Medicare, Medicaid and TRICARE are not covered. For other self-insured employer plans, contact the U.S. Department of Labor's Employee Benefits Security Administration.

Law: Va. Code 38.2-3557

Step 1: Appeal to your plan in Virginia

What it is called: Internal appeal

Each insurer must have an internal appeal process, including one for urgent care appeals. If you have a managed care plan (HMO or PPO), the Bureau of Insurance's Office of the Managed Care Ombudsman can help you understand your rights and file an appeal (call 1-877-310-6560, option 3).

Law: Va. Code 38.2-3558, 38.2-5904

All the details →

Step 2: Outside review in Virginia

External Review

Deadline to ask: 120 days.

All the details →

Urgent care in Virginia: faster decisions

Outside review

You can ask for expedited review if the denial involves cancer, if waiting would seriously jeopardize your life or health or your ability to regain maximum function, or if it concerns an admission, continued stay or service after emergency care and you have not been discharged. The Bureau of Insurance says the reviewer decides within 72 hours for medical necessity and within 6 business days for experimental or investigational treatment. Expedited review is not available for care already received.

Law: Va. Code 38.2-3557, 38.2-3560, 38.2-3561, 38.2-3562, 38.2-3563, 38.2-3564, 38.2-3569; Va. Code 14VAC5-216

Medicaid

You can ask for an expedited appeal if the normal 90-day timeline could jeopardize your life, health or ability to attain, maintain or regain maximum function. If DMAS grants it, the appeal is decided within 72 hours of receiving the request for service denials (including Medicaid managed care plan decisions), or within 7 business days for eligibility claims and some nursing facility claims.

Law: 12VAC30-110-35, -100, -160

Marketplace

If a delay could seriously jeopardize your life, health, or ability to attain, maintain or regain maximum function, you can ask for an expedited (fast-track) appeal on the form; the Marketplace will tell you if it is approved.

Complaints about your plan in Virginia

For other problems with an insurer, file a complaint with the Bureau of Insurance. Mailing address: P.O. Box 1157, Richmond, VA 23218; phone 804-371-9741 or 1-877-310-6560; email Bureauofinsurance@scc.virginia.gov.

www.scc.virginia.gov

Medicaid (Virginia Medicaid (Cardinal Care) and FAMIS) denials in Virginia

Who holds the hearing: DMAS Appeals Division.

Hearing deadline: 30 days

All the details →

Marketplace decisions in Virginia

Marketplace

Virginia's Insurance Marketplace · 1-888-687-1501

Appeal deadline

90 days

The date of the eligibility determination notice

How to appeal

Submit your appeal through your Marketplace account, by phone through the Consumer Assistance Center at 1-888-687-1501, or by mail to Virginia's Insurance Marketplace, Document Processing, ATTN: APPEALS, P.O. Box 428, Birmingham, AL 35201. Medicaid and FAMIS eligibility appeals go to DMAS instead.

Source: create a ticket and upload the Appeal Request Form

Form

Virginia's Insurance Marketplace Consumer Appeal Request Form

Faster appeal

If a delay could seriously jeopardize your life, health, or ability to attain, maintain or regain maximum function, you can ask for an expedited (fast-track) appeal on the form; the Marketplace will tell you if it is approved.

Other rights in Virginia

Cancer treatment denials

If a denial relates to treatment of your cancer, you do not have to finish the insurer's internal appeal first and you can ask for an expedited external review.

Law: Va. Code 38.2-3560(A), 38.2-3562(A)

If the insurer does not send records

If the insurer does not send the reviewer its documents within 5 business days, the reviewer may end the review and reverse the denial.

Law: Va. Code 38.2-3561(E)

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Virginia and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Virginia

Good to know in Virginia

  • Virginia lets people skip the insurer's internal appeal and get expedited external review when the denial involves cancer treatment.

    Law: Va. Code 38.2-3560, 38.2-3562

  • Self-insured employer plans can opt in to Virginia's state external review.

    Law: Va. Code 38.2-3557(B)

  • Most Virginia Medicaid hearing requests are due within 30 days of receiving the notice, but MCO members have 120 days after the MCO's final decision.

Changes in 2024–2026

Starting with plan year 2024, Virginia's Insurance Marketplace runs its own enrollment platform instead of HealthCare.gov, so Marketplace eligibility appeals go to Virginia's Insurance Marketplace (Virginia's Insurance Marketplace, FAQs).

Questions about appeals in Virginia

How long do I have to appeal a health insurance denial in Virginia?

Virginia's statute leaves the filing time to Bureau of Insurance rules. Use the deadline on your denial notice; federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Virginia?

External Review. Contact the Bureau of Insurance first (externalreview@scc.virginia.gov) to discuss your case and which forms you need. File the External Review Request Form with the Bureau, plus Form 216-B if someone acts for you, Form 216-C (physician certification) for expedited review, or Form 216-D for experimental or investigational denials.

Is outside review free in Virginia?

External review is free. The insurer pays the independent review organization.

How long do I have to ask for a Medicaid fair hearing in Virginia?

30 days. The date you receive the written notice (presumed 5 days after mailing)

Can I keep my Medicaid benefits while I appeal in Virginia?

You can ask to keep your coverage during the appeal if you file before the date coverage ends or within 10 days of the date on the notice. You must ask for it; it is not automatic.

How do I appeal a Marketplace decision in Virginia?

Submit your appeal through your Marketplace account, by phone through the Consumer Assistance Center at 1-888-687-1501, or by mail to Virginia's Insurance Marketplace, Document Processing, ATTN: APPEALS, P.O. Box 428, Birmingham, AL 35201. Medicaid and FAMIS eligibility appeals go to DMAS instead.

Not about a denied claim?

Nearby states

Sources

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