Rhode Island Health Care Rights

Rhode Island has an external review process in place if the health plan's two levels of internal appeal fail to give you, the consumer, the health care or medical procedure you feel that you need. If you receive an adverse determination after completing the second level of internal appeals, you may apply for external review.

The review agent that rendered the adverse decision will tell you where to appeal. Either you or your authorized representative can appeal any adverse decisions by a review agent that failed to certify a health care service. After denial for coverage has been appealed through the 2nd level of the health plan's internal process, you must file an external appeal within 60 days. Notices of adverse decisions will contain instructions for how to initiate the next level of appeal. You must pay half of the cost of the review. That cost depends on which external review agency is used. If you win your payment will be refunded.

The Rhode Island external review process works like this. You will select the external review agency. The review agent that turned you down must provide information to the external appeals agency within 5 days of receiving the initial notification of appeal. The external appeals agency will review the information and make a determination. However, the appeal will not be proceed until the fee and all required documentation is received. You will get a decision within 10 business days. In an emergency, an expedited appeal will be reviewed and decided by the external appeals agency within 2 days.