Appeal
Request an independent external review
Take the decision to reviewers outside the plan, whose decision the plan must follow.
Do this today
- Use the tool: External review planner Find out where to file for an independent review in your state, the deadline, the fee and what to send.
- Read: How external review works 6 minute read. External review sends a denial to independent reviewers outside your plan, and their decision binds the plan. Learn which denials qualify, who runs it for your plan, the four-month deadline, timing and cost.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- External review is a review by an independent reviewer outside your plan. If the reviewer sides with you, the plan must follow the decision.
- You usually have four months after your final internal denial to ask. If you are not sure which kind of plan you have, use four months from the final denial letter. Federal deadlines are 45 days for a standard decision and 72 hours for an expedited one.
- Three routes exist: a state process, a federal process run by private accredited reviewers, and a federal process run by the government. Which one applies depends on your plan and your state.
- It is free under the federal processes. A state process may charge up to $25 where state law allowed that fee in 2015.
More guides, tools and letters
More guides, tools, letters 17
Guides
- External review for self-funded employer plans
If your employer pays claims itself, your state's external review law generally does not apply. Learn how the federal route through private accredited reviewers works, who to call for help, and the limits.
- How external review works
External review sends a denial to independent reviewers outside your plan, and their decision binds the plan. Learn which denials qualify, who runs it for your plan, the four-month deadline, timing and cost.
- How to request external review
Step-by-step help to ask for an independent external review. Start by reading your final denial letter. Then send the request, add evidence and ask for a fast decision.
- What to expect from an external review decision
How long an external review decision takes and what the notice says. Also what the plan must do if you win, and what options remain if the reviewer sides with the plan.
Tools
- Tool
External review planner
Find out where to file for an independent review in your state, the deadline, the fee and what to send.
Letters and scripts
- Letter or script
Request expedited external review
Ask for a fast independent review, decided within 72 hours, when waiting could seriously harm your health.
- Letter or script
Request external review
Ask for an independent review of your plan's final denial by reviewers outside the plan. The decision binds you and the plan, except where other legal remedies exist.
Checklists
- Checklist
External review request
How to ask for an independent review of a final denial: the four-month deadline, which process and form apply, and the fast option.
Programs and services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Coverage Rights state-by-state appeal steps
A nonprofit website that gives each state's steps for appeal, external review and complaint when an insurer denies or delays a treatment, with a focus on medicines. No helpline or letters.
From Aimed Alliance
- Program or service
Federal external review run for the Department of Health and Human Services
The federal independent review for some denied claims. A federal contractor, MAXIMUS Federal Services, reviews medical-judgment denials and coverage cancellations when your plan or state uses this process.
From Centers for Medicare & Medicaid Services
- Program or service
HealthCare.gov: how to appeal a health plan decision
The federal explanation of the two steps for a denied claim or cancelled coverage: an internal appeal with your plan, then external review by an independent third party.
From HealthCare.gov (Centers for Medicare & Medicaid Services)
- Program or service
Maryland Insurance Administration: appeals and grievances
Maryland's insurance regulator explains the state appeals and grievances law: you first use your plan's own grievance process, then you can ask the Insurance Administration to review a denial of medically necessary treatment.
From Maryland Insurance Administration
- Program or service
Massachusetts Office of Patient Protection: external review
Massachusetts runs independent review of health plan decisions based on medical necessity. You have 4 months from your plan's final denial letter to ask, and an eligible request gets a final and binding decision.
From Massachusetts Health Policy Commission, Office of Patient Protection
- Program or service
New York Department of Financial Services: external appeal
If a New York insurer or health maintenance organization denies care as not medically necessary, experimental or out of network, you can ask the state for an external appeal. You have 4 months from the plan's final decision.
From New York State Department of Financial Services
- Program or service
Texas Department of Insurance: appeal, external review and complaints
The Texas Department of Insurance explains how to appeal a denied treatment, ask for an independent external review and file a complaint. It helps with fully insured plans and cannot overturn a reviewer's decision.
From Texas Department of Insurance
- Program or service
Triage Cancer state-by-state health insurance appeals toolkit
Free downloadable toolkit with general appeals guidance plus a section and forms for each state. Made by a cancer-focused legal-education nonprofit, but the page describes it as for people using health insurance and challenging denials.
From Triage Cancer
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.