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Independent external review: how it works

External review is an independent look at certain denials after the plan's own appeal process. For plans that must offer it, the plan must accept the reviewer's decision.

What can go to external review

• Denials that involve medical judgment where you or your provider disagree with the plan
• Denials based on a finding that a treatment is experimental or investigational
• Cancellation of coverage (rescission) based on the insurer's claim that you gave false or incomplete information when applying

A plain coverage exclusion (the plan never covers it) may not qualify. The notice you receive should explain.

Deadlines and timing (federal standard, per HealthCare.gov)

• File within 4 months of receiving the final denial from the insurer. Your state may differ.
• Standard decision: as soon as possible, no later than 45 days after the request is received.
• Expedited decision: no later than 72 hours or less, depending on medical urgency. If urgent, you can ask for external review at the same time as the internal appeal.
• Cost: free in the HHS-administered federal process; if your insurer uses an independent review organization or a state process, any charge can't be more than $25 per review.

State or federal?

Insurers in 46 states (including DC) plus Puerto Rico follow a state process that meets the federal standards. Alabama, Florida, Georgia, Texas and Wisconsin, plus other U.S. territories, use the federal process (HHS-administered or private accredited reviewers). Self-funded employer plans follow a federal process. See your state page; your final denial notice names who handles your review.

How to ask

1. Use the form and instructions in your final denial notice. If you have none, use the cover letter.
2. Include your final denial, your appeal and the plan's answers, and clinician letter.
3. You can appoint your doctor or another representative to file for you, using the authorization form.

Medicare Advantage is different: if the plan upholds its denial, the case is forwarded automatically to an independent review entity. See the Medicare and Medicaid basics.