How external review works

External review is the step after your plan’s own appeal. Reviewers who do not work for your plan look at the denial again, and if they decide the plan was wrong, the plan has to follow the decision. For plans that are not grandfathered, you usually have four months after your final internal denial to ask. It is free under the federal processes.

What this means

Federal rules require every group health plan and insurer that is not grandfathered to offer external review. A grandfathered plan is one in place since March 2010 that has kept its old status. It does not have to offer the general review, but it must offer review for disputes under the surprise-billing law.

Not every denial qualifies. Under the federal process these can go to review:

• Denials that involve medical judgment: medical necessity, appropriateness, the setting of care, level of care, effectiveness, whether a treatment is experimental or investigational, and whether the plan followed the mental health parity rules for limits like prior authorization.
• Denials that turn on whether the plan followed the surprise-billing and cost-sharing protections.
• A rescission, which is a retroactive cancellation of coverage.

A denial that says you are not eligible for the plan does not qualify. The reviewer decides whether medical judgment is involved, so a visit-limit or out-of-network denial can qualify if it turns on medical judgment.

Three routes, and which one is yours

Which route applies depends on how your plan is funded and where you live. The distinction matters, so read this part carefully.

• A state process. An insurer bound by a state external review process that meets the federal standards uses it. The state, or an independent body it chooses, assigns the reviewer. Your insurer never picks the reviewer.
• The federal process run through private accredited reviewers. A self-funded employer plan uses this one. The plan hires at least three accredited independent review organizations and rotates cases among them. See external review for self-funded employer plans.
• The federal process run by the government. Where a state process does not meet the federal standards, the insurer can choose either private accredited reviewers or the process the Department of Health and Human Services (HHS) runs through a contractor.

The Centers for Medicare & Medicaid Services (CMS) publishes a list of which states use which process. The version we checked on 11 November 2026 carried a table dated July 2024. It lists 45 states and the District of Columbia as having a qualifying state process. It lists Alabama, Florida, Georgia, Texas and Wisconsin, with some territories, as using the federal process. Our own state pages describe some of these states differently, for example Georgia and Wisconsin as having both a state and a federal route. If your state is one of them, check your state page and your own denial letter. The letter must explain how to start external review, so look there for where to send the request. Start at all states or use the external review planner.

What to do

1. Find out which process you have. Read your final denial letter. It must explain how to start external review. If it does not, ask the plan in writing.
2. Write down your deadline. You must be allowed at least four months after receiving the denial or final internal denial. If you are not sure which kind of plan you have, use four months from the final denial letter. For retiree coverage from a former employer, ask the plan administrator whether your retiree plan is an employer plan. Check the date on your notice, which controls.
3. Decide whether you can skip the internal appeal. Exhaustion is not required if the plan waives it, if the plan failed to follow the appeal rules (see when the plan goes silent), or if you ask for expedited review at the same time as an expedited internal appeal.
4. Ask your doctor to support the request. The reviewer weighs your medical records, your treating professional’s recommendation, the plan’s terms and evidence-based practice guidelines.
5. File the request. See how to request external review.

How long it takes and what it costs

A standard decision is due within 45 days after the independent reviewer receives the request. An expedited decision is due as fast as the medical situation requires and no later than 72 hours. Expedited review is open when waiting would seriously jeopardize life, health or ability to regain maximum function, and after a final internal denial about an admission, care availability, a continued stay, or emergency services while you are still in the hospital.

The federal processes are free to you. A state process may charge a fee only if state law expressly allowed it as of 18 November 2015. The fee may not exceed $25, must be refunded if you win, must be waived for financial hardship, and may not exceed $75 per person per plan year. Your plan or insurer pays the reviewer.

What the plan may say, and what to say back

“You have to finish all our appeals first.” Not always. Ask whether the plan waives that, and say whether you meet an exception. Ask for the answer in writing.

“External review does not apply to this kind of denial.” Ask which rule says so. Under the federal process, the independent reviewer decides whether the denial involves medical judgment, not the plan.

The rule

Every non-grandfathered group health plan and insurer must offer external review, either under a state process that meets the federal standards or under a federal process. The decision binds the plan and the claimant “except to the extent other remedies are available under State or Federal law”. If the denial is overturned, the plan must provide coverage or payment immediately. See title 29 of the Code of Federal Regulations (CFR), section 2590.715-2719(c) and (d) and 45 CFR 147.136.

Watch for

• Plans with no federal external review. Short-term plans, fixed indemnity products and health care sharing ministries are outside these rules.
• The wrong door. A request sent to the wrong place can lose time. Use the address in the final denial letter.
• A complaint is not a review request. See appeal, complaint, grievance and external review.
• Marketplace and individual plans. See marketplace and individual appeals for how this fits with your plan’s internal appeal.

What next

• How to request external review: the steps and what to send.
• External review for self-funded employer plans: what changes if your employer pays the claims.
• What to expect from an external review decision: the decision, timing and what happens if you lose.