The Office of the Managed Care Ombudsman was established in 1999 under §38.2-5904 of the Code of Virginia. The Office helps Virginia consumers whose health insurance is provided by a Managed Care Health Insurance Plan (MCHIP), such as a Health Maintenance Organization or a Preferred Provider Organization. The principal responsibilities include the following:

Protecting the interests of consumers whose health insurance is provided by a MCHIP by:

• Assisting consumers in understanding their rights and how to resolve problems.
• Answering inquiries from consumers, health care providers, and other individuals.
• Providing information on MCHIPs, types of MCHIPs, mandated benefits, utilization review procedures and available appeal options.
• Assisting consumers in filing appeals, including utilization review appeals.
• Ensuring consumers have access to the Office and receive timely responses.

Contact Information for the Managed Care Ombudsman:

If you are a consumer, health care provider or other individual with a general question or have an inquiry regarding MCHIPs, managed care, health insurance or related subjects, you can contact the Office via the following:

• Toll free phone 1-877-310-6560, select option 1
• Fax (804) 371-9944
• Office of the Managed Care Ombudsman, Bureau of Insurance, P.O. Box 1157, Richmond, Virginia 23218
• ombudsman@scc.virginia.gov

Help from the Office of the Managed Care Ombudsman:

If you are a consumer and would like assistance in appealing an adverse decision rendered by an MCHIP, you can initiate contact with the Office as described above. In order for the Office to formally help you file an appeal, you will need to complete a Life and Health Insurance Complaint/Appeal Form which documents your written authorization. We suggest you call the Office prior to completing the form. If your problem is outside the scope of the Office, the staff will refer you to another section or agency for assistance.

Life and Health Insurance Complaint/Appeal Form

General Questions

• How can the Bureau of Insurance assist me?
• Should I ask for assistance from the Office of the Managed Care Ombudsman?
• What should I know about my coverage and my rights to appeal?

How to Appeal a Denial

• What are the steps of a typical appeal process?
• How do I appeal a denial from my Managed Care Health Insurance Plan (MCHIP)?
• My medication has been denied. What should I do now?
• I have a special needs child. What coverage does Virginia law require?
• My MCHIP has denied payment for my requested service because it says the service is experimental/investigational. What is the best way to appeal this decision?
• What should I know about obtaining services outside my MCHIP’s provider network?

If Your Coverage is Self-Insured

• I work for a large employer and my coverage is self-insured. What does this mean and where do I go for help with an appeal?

Office of Independent External Review

• Independent External Review process for adverse determinations

Miscellaneous

• What are Mandated Benefits/Offers?
• View Annual Reports of the Office of the Managed Care Ombudsman
• List of Bureau Consumer Guides