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

In Washington, your health plan is regulated by Washington State Office of the Insurance Commissioner (OIC), if it is a state-regulated plan.

Washington runs its own independent review of denials: Independent Review (Independent Review Organization, IRO). You generally have 180 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.

Washington Apple Health

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

Marketplace (Washington Healthplanfinder (Washington Health Benefit Exchange)) 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 Washington?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
180 days
Hearing deadline
90 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Washington Healthplanfinder (Washington Health Benefit Exchange)
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

Find out whether you have a group, individual or government-sponsored plan. Employer-sponsored self-funded plans, Medicare, TRICARE and Apple Health follow their own appeal processes; the OIC regulates individual plans and insured plans from carriers.

Step 1: Appeal to your plan in Washington

What it is called: Review of an adverse benefit determination (internal appeal)

The carrier must confirm it received your appeal within 72 hours. It must decide within 14 days (20 days if the denial involves experimental or investigational treatment); for good cause it can take up to 16 more days, and state law caps a standard appeal decision at 30 days. An expedited appeal must be decided as fast as possible, preferably within 24 hours and no later than 72 hours. You have the right to see and get free copies of all documents relevant to your claim, and any new evidence the carrier relies on must be given to you before the decision. If the carrier wants to cut or stop ongoing treatment because it is no longer medically necessary, it must keep covering it until the appeal is resolved (you may owe the cost if you lose). Reviews involving medical judgment must be done by someone not involved in the first decision with training in your condition. Individual plans may have only one level of internal review.

Law: RCW 48.43.530(4)-(7); WAC 284-43-3030(4), 284-43-3110, 284-43-3170

All the details →

Step 2: Outside review in Washington

Independent Review (Independent Review Organization, IRO)

Deadline to ask: 180 days.

All the details →

Urgent care in Washington: faster decisions

Appeal to your plan

  • Your plan must decide an urgent appeal within 72 hours.

Outside review

Expedited review is available if the denial concerns an admission, continued stay or care after emergency services and you have not been discharged, or if the standard time could seriously jeopardize your life, health or ability to regain maximum function. If your treating provider says a delay could jeopardize your health, the carrier must treat it as expedited. The IRO must decide within 72 hours, with written confirmation within 48 hours if the first notice was not in writing.

Law: RCW 48.43.535; WAC 284-43-3070, 284-43-3130, 284-43-3150(5), 284-43-3170, 284-43A-070, 284-43A-140

Standard: 20 days

Medicaid

Ask OAH for an expedited hearing if waiting could jeopardize your life, health or ability to attain, maintain or regain maximum function, and send evidence of the urgent need with the request. The judge must decide whether to grant it within 4 business days. People who are getting continued coverage may not get an expedited hearing.

Law: RCW 74.09.741(4); WAC 182-526-0095, 182-526-0102

Marketplace

You can ask for an expedited hearing and explain or document an immediate need for health services. If granted, the hearing is scheduled immediately and the judge decides within 14 calendar days.

Law: Appeal Request Form (2022-11)

Complaints about your plan in Washington

File a complaint with the OIC if you think an insurer or agent broke the law or treated you or your claim unfairly. The OIC sends the complaint to the insurer and asks for a response. You can file a complaint and an appeal at the same time.

www.insurance.wa.gov

Medicaid (Washington Apple Health (Medicaid)) denials in Washington

Who holds the hearing: Washington State Office of Administrative Hearings (OAH); HCA Board of Appeals reviews initial orders.

Hearing deadline: 90 days

All the details →

Marketplace decisions in Washington

Marketplace

Washington Healthplanfinder (Washington Health Benefit Exchange) · 1-855-859-2512

Appeal deadline

90 days

The date on the eligibility notice (eligibility results) you disagree with

How to appeal

Fill out the Appeal Request Form and send it by email to appeals@wahbexchange.org, by fax to 360-841-7653, or by mail to Washington Health Benefit Exchange, ATTN: Appeals Program, PO Box 1757, Olympia, WA 98507; or appeal online, by phone at 1-855-859-2512, or in person at 810 Jefferson Street SE, Olympia. An Appeals Specialist sets up a prehearing conference with a judge by phone; a hearing follows if needed. Apple Health eligibility appeals go to HCA. An appeal received after 90 days is not valid unless you send a written good-cause explanation showing the delay was due to exceptional circumstances.

Form

Washington Healthplanfinder Appeal Request Form (individual)

Faster appeal

You can ask for an expedited hearing and explain or document an immediate need for health services. If granted, the hearing is scheduled immediately and the judge decides within 14 calendar days.

Coverage while you appeal

To keep your tax credit, child care sponsorship or Cascade Care Savings during the appeal, appeal within 10 days of the date on the eligibility notice or within 10 days of the loss or reduction. To keep Apple Health, appeal within 10 days of the date on the notice or before coverage ends. You may have to repay tax credits you were not eligible for.

If you disagree

If you disagree with the judge's ruling, you can file a second-level appeal; instructions come with the decision.

Law: Appeal Request Form (2022-11)

Other rights in Washington

How fast a plan must decide a prior approval

Once the carrier has the information it needs, it must decide a standard prior authorization within 3 calendar days for electronic requests or 5 calendar days for other requests (fax, phone, mail), and an expedited request within 1 calendar day (electronic) or 2 calendar days (other).

Law: WAC 284-43-2050(10); RCW 48.43.830

Who can deny care for medical necessity

Only a licensed physician or licensed health professional may deny a prior authorization based on medical necessity, after considering your provider's recommendation and your history. Artificial intelligence cannot be the only means used to deny, delay or change care, and algorithms cannot deny care for medical necessity without human review.

Law: RCW 48.43.830(3)

Ongoing treatment during an appeal

If your carrier wants to reduce or end a covered service you are receiving because it is no longer medically necessary, it must keep providing it until the appeal and any independent review are decided, if you ask. If you lose, you may have to pay for that care.

Law: RCW 48.43.530(7); RCW 48.43.535(9)

How long do I have? Deadline calculator

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

Good to know in Washington

  • Washington gives 180 days (not 4 months) to ask for independent review of a final internal denial.

    Law: WAC 284-43-3150(5)

  • Apple Health managed care members can ask for an independent review organization to look at a judge's initial order within 21 days.

    Law: WAC 182-526-0200(8)

  • If you lose an Apple Health appeal after keeping coverage, the state can recover only the first 60 days of continued benefits.

    Law: RCW 74.09.741(5)(g)

Changes in 2024–2026

Prior authorization deadlines for state-regulated plans were tightened and electronic-request rules updated, with a prior-authorization API required from January 1, 2027. RCW 48.43.830(3) limits the use of artificial intelligence and algorithms to deny care. A 2026 law (2026 c 157) amended RCW 48.43.535; a new version of the independent review statute takes effect January 1, 2027, adding that reviews of mental health and substance use disorder services must follow RCW 48.43.766. RCW 74.09.741 (2022 c 163) set the 90-day Apple Health hearing deadline with a one-year good-cause limit; WAC 182-526-0020 was updated November 9, 2024.

Law: WAC 284-43-2050, amended effective January 27, 2025 and January 19, 2026; RCW 48.43.830

Questions about appeals in Washington

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

Your carrier must accept a request for internal review received within 180 days of when you received the decision, the same as the federal minimum. You can ask orally or in writing, and you do not have to file a complaint first. 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 Washington?

Independent Review (Independent Review Organization, IRO). Ask your carrier for independent review as explained in its final decision letter. The carrier assigns a certified IRO from the Insurance Commissioner's rotational registry and must tell you the IRO's name and contact information within one day.

Is outside review free in Washington?

The carrier must provide independent review at no cost to you or your provider and pays the IRO's charges.

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

90 days. The date you receive the notice of the decision

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

To keep your Apple Health coverage while you appeal a decision to end, suspend or reduce your eligibility or an authorized service, request a hearing by the tenth day after the notice was sent or by the last day of the month before the change takes effect. If that day is a weekend or holiday, you have until 5:00 p.m. the next business day.

How do I appeal a Marketplace decision in Washington?

Fill out the Appeal Request Form and send it by email to appeals@wahbexchange.org, by fax to 360-841-7653, or by mail to Washington Health Benefit Exchange, ATTN: Appeals Program, PO Box 1757, Olympia, WA 98507; or appeal online, by phone at 1-855-859-2512, or in person at 810 Jefferson Street SE, Olympia. An Appeals Specialist sets up a prehearing conference with a judge by phone; a hearing follows if needed.

Not about a denied claim?

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