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

In West Virginia, your health plan is regulated by West Virginia Offices of the Insurance Commissioner (OIC), Life and Health Consumer Services, if it is a state-regulated plan.

West Virginia runs its own independent review of denials: Independent External Review. You generally have 4 months 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.

West Virginia Medicaid

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

Marketplace (HealthCare.gov) 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 West Virginia?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
90 days
Appeal to the plan first
60 days (federal rule)
Appeal deadline – HealthCare.gov
90 days (federal rule)

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How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

West Virginia's external review is not available for Medicaid, WV CHIP, Medicare (including services through a contracted health insurer), other government health programs, or health plans that employers fund themselves (self-funded plans).

Step 1: Appeal to your plan in West Virginia

What it is called: Internal grievance with your health plan issuer

Your issuer must have internal grievance procedures under OIC Rule 114-96. If the issuer has not given you a written decision within 30 days after you filed a grievance about a denial (and you did not ask for or agree to a delay), you are treated as having finished the internal process and can ask for external review.

Law: W. Va. Code 33-16H-2; W. Va. Code St. R. 114-96, 114-97-5.2

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Step 2: Outside review in West Virginia

Independent External Review

Deadline to ask: 4 months.

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Urgent care in West Virginia: faster decisions

Outside review

Expedited review is for people who would be significantly harmed by waiting. Check the expedited box on the form and have your treating provider complete the certification that the standard time frame would seriously jeopardize your life or health or your ability to regain maximum function. You may ask orally. Call the OIC at 304-558-3386 or 888-879-9842 before sending paperwork. Expedited reviews must be completed within 72 hours.

Law: W. Va. Code 33-16H-1 to 33-16H-4; W. Va. Code St. R. 114-97-5, 114-97-6, 114-97-7, 114-97-13

Complaints about your plan in West Virginia

For other problems with a health insurer, file a complaint with the OIC online (NAIC portal) or with the paper Life and Health Consumer Complaint form. Contact: 1-888-879-9842, 304-720-8584, OICConsumerServicesLH@wv.gov, fax 304-558-4965.

sbs.naic.org

Medicaid (West Virginia Medicaid (Mountain Health Trust for managed care)) denials in West Virginia

Who holds the hearing: West Virginia Office of Inspector General, Board of Review.

Hearing deadline: 90 days

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Marketplace decisions in West Virginia

West Virginia uses HealthCare.gov. Appeals go to the federal Marketplace Appeals Center.

HealthCare.gov

1-855-231-1751

Other rights in West Virginia

Court review of an external review decision

You or the insurer can ask the circuit court to review an external review decision within 60 days after receiving it. The insurer must pay benefits under the decision unless a court decides otherwise. If the insurer goes to court and you substantially win, the insurer pays your reasonable attorney's fees.

Law: W. Va. Code 33-16H-3

How long do I have? Deadline calculator

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

Good to know in West Virginia

  • West Virginia counts the 90-day Medicaid hearing deadline from the effective date of the action, not from the date of the notice.
  • West Virginia Medicaid notices must be mailed at least 13 days before an adverse change takes effect.
  • If an insurer takes an external review decision to court and you substantially prevail, the insurer must pay your reasonable attorney's fees.

    Law: W. Va. Code 33-16H-3(a)(3)

Changes in 2024–2026

From January 1, 2027, certain adults 19-64 in the Medicaid Adult Expansion Group must complete 80 hours per month of qualifying activities (or earn at least $580 a month) to keep coverage (WV DoHS/BMS announcement, August 27, 2026). The Board of Review hearing rules (Common Chapters 700) were revised August 22, 2024.

Questions about appeals in West Virginia

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

West Virginia follows the federal 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 West Virginia?

Independent External Review. Fill out the "Request for Independent External Appeal of a Healthcare Decision" form and send it with: the insurer's final internal denial letter, a copy of your insurance card, your certificate of coverage or benefit booklet if available, and any medical records or provider statements you want considered. Email it to OICHealthPolicy@wv.gov, or mail it to WV Offices of the Insurance Commissioner, ATTN: Health Policy Department, PO Box 50540, Charleston, WV 25305-0540 (fax 304-558-4965).

Is outside review free in West Virginia?

There is no cost to you. The insurer pays the cost of the external review.

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

90 days. The effective date of the action

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

Notices of adverse action must be mailed at least 13 days before the change takes effect. If you are receiving benefits and ask for a hearing before the effective date of the action, the action is delayed until the hearing decision.

Who regulates health insurance in West Virginia?

West Virginia Offices of the Insurance Commissioner (OIC), Life and Health Consumer Services. West Virginia's external review is not available for Medicaid, WV CHIP, Medicare (including services through a contracted health insurer), other government health programs, or health plans that employers fund themselves (self-funded plans).

Not about a denied claim?

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