Written by a parent, not a doctor. Nothing here is medical advice.

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Washington program

Get an independent review of an insurance denial

After a denial, a reviewer outside the insurer can overturn it. Urgent cases can be decided within 72 hours.

What it is

After a denial, a reviewer outside the insurer can overturn it. Urgent cases can be decided within 72 hours.

If an insurer pays the claims on your plan, Washington’s outside review applies: 180 days to ask after the final internal denial, decisions ordinarily within 15 to 20 days, 72 hours when urgent. If the employer pays the claims itself, a federal route applies instead. One question to HR helps identify which; the plan administrator confirms.

Which plans
  • State-regulated health plans; a private employer’s self-funded plan usually uses federal procedures; state and school employee plans are covered by a separate statute.
  • “Fully insured” does not by itself mean Washington-regulated; check the policy and administrator.
What you get
  • A decision outside the insurer that binds the plan when it applies.
  • Concurrent urgent internal and external review when waiting could harm your child.
Timing
  • Request within 180 days of the final adverse decision. Ordinary review within 15 days after necessary information or 20 after referral, whichever is earlier, extendable to 25 days when information is unavailable; urgent within 72 hours.
  • Running an urgent internal appeal and urgent external review at the same time comes from the federal rule (45 CFR 147.136) for plans it covers, not from a Washington-only rule.
If you decide to apply
  1. Give the denial letter to the oncology team and ask which appeal step applies.
  2. Collect the denial, the clinician’s supporting letter and prior appeal records.
  3. Request the independent or urgent review before the deadline.

Office of the Insurance Commissioner · Official page ↗

During review
  • Ask whether existing treatment can continue during review and about possible repayment.
Good to know

An independent review is not a guarantee of approval. Its value is that the decision is made outside the insurer.

One question for HR
  • Does an insurer pay the claims, or does the employer? That decides the route for this and the next two cards.

Federal background: Ask for a review when insurance says no (appeals) · Find out which insurance rules apply.

Official sources
Ask your social worker

“If our insurance denies part of treatment, which review route applies to our plan, and can the team ask for the urgent version?”

Why I’m asking: We want the right review without delaying treatment.

More background and detailed requirements

How this could help

Start with the denial letter: it should explain why coverage was refused and the appeal process. The treating team can supply medical evidence. If the internal appeal is complete, the Washington external-review route may be available for an eligible plan and dispute.

An independent review is not a guarantee of approval. Its value is that the decision is reviewed outside the insurer, and an applicable decision binds the plan. Ask immediately about expedited handling when waiting could harm your child.

Qualifying urgent cases can use concurrent expedited internal and external review. Washington’s request and decision deadlines are not the federal external-review deadlines. Confirm which system governs the actual plan.

What to know before you apply

  • The Washington route generally gives 180 days after the final adverse decision to request review.
  • Ordinarily 15 days after necessary information or 20 after referral, whichever is earlier; limited exceptions apply. Urgent review is at most 72 hours.
  • Private employer self-funded plans usually use federal procedures; state and school employee plans have separate provisions.

Your next steps

  1. Ask the oncology team and insurer which appeal step applies to the denial letter.
  2. Collect the denial, medical supporting letter and prior appeal records.
  3. Request the appropriate independent or urgent review before the deadline.

state-regulated health plans; the ordinary definition excludes a private employer's self-funded plan, and state and school employee plans are brought in by a separate statute

within 180 days of the final adverse determination

Washington-regulated coverage

Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask within 180 days and say whether it is urgent.

Your social worker

The plan sends the file to the reviewer and follows the result.

The care team

The oncologist writes why the treatment is needed and what waiting would cost.

Who decides
An independent review organisation certified by the state.
Ask your social worker
“Could this denial be appealed or independently reviewed, and is there a faster route because treatment is time-sensitive?”

How to apply

First step: Ask the oncology team and insurer which appeal step applies to the denial letter.

  1. Finish the plan's own appeal, then ask for the outside review within 180 days.
  2. Ask for the expedited route whenever waiting would harm your child.
  3. Ask the oncology team for a letter saying why the treatment is needed now.

Official application / program page ↗

Where it starts: The final denial letter has to tell you how to ask. Ask the plan for the external review form and say whether it is urgent.

What to gather

  • The final denial letter
  • The plan's appeal file
  • The oncologist's letter

How long: 15 days after the reviewer has what it needs, or 72 hours when urgent.

Clock: 180 days from the final denial to ask for an outside review.

What a yes looks like

A written decision the plan has to follow.

What a no looks like, and the next move

If the plan says the route does not apply, ask whether it is self-funded and check with the insurance commissioner's office.

Watch out

  • The 180 days is the time to ask, not the time they take.
  • Ask for the urgent route whenever a delay would hurt your child.
  • A private employer's self-funded plan uses the federal route instead.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

180 days to ask for an outside review, decided within 15 days of the necessary information or 72 hours when urgent.

  • $180 — Days from the final denial to ask for a review
  • $15 — Days for a standard decision after the necessary information
  • $72 — Hours for an urgent decision

Legal protection: The reviewer is independent of the plan · Notice of the result follows within two business days, or at once when expedited

What it costs the family: Nothing.

The eligibility facts, as published

Plan type
state-regulated health plans; the ordinary definition excludes a private employer's self-funded plan, and state and school employee plans are brought in by a separate statute
Timing
within 180 days of the final adverse determination
Residency
Washington-regulated coverage

Decisions this site cannot make: Independent review decision

Expect friction on: Finishing the internal appeal first

The trap: The 180 days is the time to ask, not the time they take to decide. Ask for the expedited route whenever a delay would hurt your child; that turns 15 days into 72 hours. State and school employee plans carry this right by a separate statute even when they sit outside the ordinary insurance rules.

Where I read this

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