External review of an insurance denial: how does it work?
After the plan's internal appeal upholds a denial, you can ask for an independent external review, decided by an outside review organisation at no cost to you, and the decision binds the plan. It is available for denials based on medical necessity, appropriateness, setting, level of care, effectiveness, and experimental or investigational determinations, and must be requested within about four months of the final internal denial.
What to do, in order
- Step 1
Finish the internal appeal, or qualify to skip it
External review normally follows the final internal denial. Urgent cases can run at the same time, and if the plan failed to follow its own procedures you may go straight to external review.
- Step 2
Find the right process
State-regulated plans use the state's external-review process (the regulator is on your denial letter). Self-funded employer plans use the federal process or a plan-contracted IRO. Apellica's state pages and External Review Index list both.
- Step 3
File the request with the record
Send the final denial, the plan's criteria, the clinician's letter and the records. The reviewer decides on the documents; make them complete.
- Step 4
Wait for the decision, or expedite
Standard decisions come within 45 days; expedited reviews within 72 hours when a delay would jeopardise health (45 CFR 147.136(d)).
The deadline that applies
Generally four months from the date you receive the final internal adverse determination under the federal external-review process (45 CFR 147.136(d)(1)); state processes set their own windows, many of them the same. The letter states the applicable date.
Calculate your date →Documents to gather
- The final internal denial letter
- Everything submitted in the internal appeal
- The plan's criteria and the claim file
- Any new records or letters obtained since
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Related questions
Does external review cost anything?
Under the federal external-review standards a process may charge a nominal filing fee of no more than $25 per request and $75 per year, waived for hardship. Many states charge nothing.
Can the plan ignore the decision?
No. The external reviewer's decision is binding on the plan (and on you, except for other remedies available under law).
Which denials are not eligible?
Denials based purely on plan eligibility or a contractual exclusion that does not involve medical judgment are generally outside external review; those go to the regulator or to court.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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