District of Columbia program
An outside review when your plan says no
People outside your insurer can review a treatment denial after the plan's own appeal.
What it is
People outside your insurer can review a treatment denial after the plan's own appeal.
A final refusal from the insurer is not always the last word. On a plan DC regulates, the request goes through DHCF and a reviewer outside the plan decides. When waiting would harm your child, the urgent version is decided within 72 hours.
Eligibility rules
- For an eligible denial under a DC-regulated private health plan, outside review normally follows the plan’s internal appeal. Exceptions can allow earlier or simultaneous outside review, including certain urgent cases or a plan’s failure to follow required procedures. The request window is 4 months from the relevant final notice; the independent reviewer normally decides within 45 calendar days of assignment, or within 72 hours for expedited review. Medicaid and Alliance use different appeal routes.
- Treated under a District-regulated plan.
What you get
- Independent review at no charge for a District-regulated plan.
- A decision within 45 calendar days of assignment, or 72 hours for urgent review.
If you decide to apply
- Ask the DC health care ombudsman for help with an external appeal to DHCF.
- Have the internal appeal decision, signed medical-records release and the clinical team's explanation ready.
The Director of the Department of Health Care Finance assigns the review: 202-724-7491 · Official page ↗
Good to know
A private employer's self-funded plan follows federal rules instead. The plan type needs checking.
Plan scope
- A District group plan outside mandatory District regulation may use the review system voluntarily at its own expense. This is not an automatic right under that plan.
Official sources
- D.C. Code § 44-301.07 — External appeals
- D.C. Code § 44-301.01 — Definitions, Health Benefits Plan Members Bill of Rights
- D.C. Code § 44-301.11 — Voluntary use of external review
- DC Office of Health Care Ombudsman and Bill of Rights
- Office of Health Care Ombudsman — Grievances/Appeals
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
“If the plan denies treatment, could an outside review help? Could you explain the deadline and any risks of delay, then help us choose the right appeal route?”
Why I’m asking: I want to know which review route applies and how treatment urgency affects the timeline.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
File within four months with the signed records release, and say if it is urgent.
Your social worker
The ombudsman helps you write it; the oncology team writes why the treatment is needed now.
The care team
The oncologist writes a letter explaining why the treatment is medically necessary and why waiting harms the child.
- Who decides
- An independent review organisation assigned by the Director of the Department of Health Care Finance.
- Ask the agency
- “I want an expedited external appeal of this denial. My child is in active cancer treatment and waiting will harm them. Please tell me what you need from me today.”
How to apply
First step: Call the health care ombudsman on 202-724-7491 and ask them to help you file.
- Finish the plan's own appeal and keep the written decision.
- Call the ombudsman on 202-724-7491 and ask them to help you file.
- If treatment is waiting, ask for the expedited route by name.
Official application / program page ↗
Where it starts: File a written request with the Director within four months, with a signed medical-records release. The health care ombudsman helps on 202-724-7491.
What to gather
The diagnosis letter, the child’s insurance card, and the last two pay stubs cover most applications. The official page lists the rest.
How long: Forty-five days, or 72 hours when urgent, from the day it is assigned.
What a yes looks like
A written decision the plan has to follow.
What a no looks like, and the next move
Ask the ombudsman what else can be done and whether the denial can be reframed.
Watch out
- In DC this goes to the health financing department, not the insurance regulator.
- Four months from the internal panel's written decision, and you must sign a records release.
If they say no, quote this: D.C. Code § 44-301.07: the reviewer must decide within 45 calendar days, or 72 hours for an expedited appeal, from assignment.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
An independent review. Four months to file, then 45 days, or 72 hours when it is urgent.
- $4 — Months from the internal appeal decision to file
- $45 — Calendar days for the reviewer to decide, from assignment
- $72 — Hours for an urgent decision, from assignment
Legal protection: Review by an organisation outside your insurer
What it costs the family: Nothing for a DC-regulated plan.
The eligibility facts, as published
- Other
- A DC-regulated group or individual policy or contract, after the internal appeal panel has decided
- Residency
- Treated under a District-regulated plan
The trap: You have four calendar months from the written decision of the internal appeal panel, and you must send a signed form letting the insurer release the medical records.
Where I read this
- D.C. Code § 44-301.07 — External appeals — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 44-301.01 — Definitions, Health Benefits Plan Members Bill of Rights — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 44-301.11 — Voluntary use of external review — Council of the District of Columbia, read September 10, 2026
- DC Office of Health Care Ombudsman and Bill of Rights — Government of the District of Columbia, read September 10, 2026
- Office of Health Care Ombudsman — Grievances/Appeals — Government of the District of Columbia, read September 10, 2026