Office of the Managed Care Ombudsman

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.

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.

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)?
• How do I get help with a request or an appeal for coverage of a prescription drug?
• 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?
• Standard Internal Appeal Process Flowchart
• Urgent Care Internal Appeal Process Flowchart

Miscellaneous

• What are Mandated Benefits/Offers?
• View Current Annual Report of the Office of the Managed Care Ombudsman
• Life & Health Tips, Guides & Publications

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 of the Managed Care Ombudsman.

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