District Of Columbia § 44-301.04 - Grievance process.
Full text of District Of Columbia D.C. Code § 44-301.04 — Grievance process., with citation guidance and answers to common questions.
§ 44-301.04. Grievance process.
44-301.04A member or member representative may appeal any adverse benefit determination decision resulting in a rescission, denial, termination, or other limitation of a benefit in accordance with the provisions of this chapter.
At the time an insurer denies, reduces, terminates, or limits a benefit, an insurer shall provide to the affected member or member representative a written description of the procedures for filing appeals, including procedures to request expedited internal or external review if the matter concerns an emergency or urgent medical condition. The notice shall adhere to requirements of Title XXVII of the Public Health Service Act, approved July 1, 1944 (42 U.S.C. § 300gg et seq.), and the Employee Retirement Income Security Act of 1974, approved September 2, 1974 (Pub. L. No. 93-406; 88 Stat. 829), and shall include information sufficient to identify the claim, the reason for the denial, any standards relied on to deny the claim, contact information for the Health Care Ombudsman, and notice of the right of the claimant to receive free of charge all documents relevant to the claim.
The appeal process shall consist of 2 separate appeal levels:
Review by the insurer; and
External review by an independent review organization.
Nothing in the health benefits plan shall prohibit a member or member representative from discussing or exercising the right to appeal pursuant to this section.
The insurer shall notify a member seeking a resolution of an adverse benefit determination about the:
Availability of the Health Care Ombudsman;
Right to review; and
Procedures for obtaining continued coverage pending the outcome of the grievance.
For grievances and appeals concerning urgent or emergency medical conditions, the member has the right to continued coverage at the level of benefits provided before the reduction, termination, or limitation, pending the outcome of the appeal.
Any request that a physician, with knowledge of the covered person’s medical condition, determines involves an emergency or urgent medical condition shall be treated as an urgent care request.
An individual acting on behalf of the health insurer shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine to determine if other requests involve an emergency or urgent medical condition.
For the purposes of expedited external review, the Director, or the Director’s designee, shall apply the judgment of a prudent layperson that possesses an average knowledge of health and medicine to determine if other requests involve an emergency or urgent medical condition.
Annotations
Source: official District Of Columbia text · Last verified 2026-08-27
Frequently Asked Questions About District Of Columbia § 44-301.04
What does D.C. Code § 44-301.04 cover?
Section 44-301.04 ("Grievance process.") is part of the D.C. Code, the codified statutory law of District Of Columbia. It sets out the legal rule or procedure described in the text above. Statutes are amended regularly, so always verify against the official source.
How do I cite District Of Columbia § 44-301.04?
A common citation format is "D.C. Code § 44-301.04" (District Of Columbia). Legal writing may require the code abbreviation, section number, and year or edition. Match the style required by your court, professor, or publisher.
Is this the official text of District Of Columbia law?
No. This page is for research and education and may not include the most recent amendments. For official current law, check the District Of Columbia official source linked on this page or consult a licensed District Of Columbia attorney.
How does District Of Columbia § 44-301.04 apply to my situation?
Statutes are interpreted in context, and application depends on your specific facts. Only a licensed attorney in District Of Columbia can advise on how this section applies to you. Contact your state or local bar association for a referral.
Sources & Verification
Not legal advice. Verify against the official source and consult a licensed attorney in District Of Columbia.