If your claim was denied

You can appeal an insurance company's decision to deny a claim or a decision to pay less than the amount billed. The Insurance Division can explain the appeals process. Call one of our insurance experts or file a complaint to get help. Here's an overview.

Complaint and appeals process

  • Your insurance company must acknowledge nonemergency complaints and appeals within seven days.
  • Your insurance company must make a decision and respond within 30 days.
  • If your insurance company needs more time, it must tell you the reason and send a decision within 15 additional days. No further extension is allowed.
  • Your insurance company must have a process for responding to emergency complaints (expedited review) more quickly.
  • If your insurance company rejects your first appeal and your plan is through an employer, you may have the right to a second appeal.
  • Your insurance company has seven days to acknowledge each appeal and 30 days to respond.
  • If your insurance company rejects all appeals, you have the right to an independent external review to determine:
    • Whether treatment is medically necessary.
    • Whether treatment is experimental or investigational.
    • Whether treatment is for continuity of care.
    • Other "adverse benefit" issues such as the insurance company rescinded or ended your coverage.

GET THE HELP YOU NEED

1-888-877-4894

cp.ins@state.or.us

Connect with an insurance expert.

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Key links

External review
Appeals guide