How to request an external review

External review is a third-party independent review of your appeal by a reviewer who does not work for the insurer. It is one of the strongest tools you have as a consumer. Under ACA section 2719 (45 CFR 147.136), non-grandfathered plans must offer external review after you exhaust internal appeals.

Who qualifies

You can request an external review if:

• Your plan is non-grandfathered (most plans since 2014)
• You exhausted the plan's internal appeal process (or the plan missed a deadline and you invoke deemed exhaustion)
• The denial involved medical judgment (medical necessity, appropriateness, experimental, level of care)
• The denial involved a rescission of coverage

External review does not apply to purely administrative denials that had no medical judgment component.

Which reviewer

There are two systems, depending on your state:

• State-based external review: most states run their own review process, usually administered through the state insurance department. This is standard for fully-insured commercial and individual plans in a state that has been approved by HHS.
• HHS-administered federal external review: for plans in states without an approved external review process, or for self-funded ERISA plans that use the HHS process by default.

Your plan's denial letter must tell you which system applies to you. If it does not, ask the plan in writing.

The four-month window

You have four months from the date of the final internal denial to request external review (45 CFR 147.136(d)(1)). Do not miss it. Set a calendar reminder.

What to include

Every external review request should include:

• A written request (form or letter) identifying the appeal
• A copy of the plan's final internal denial
• A copy of your appeal(s) and any supporting documentation
• The plan's Explanation of Benefits or denial letter
• The clinical documentation from your provider (for medical-necessity denials)

If you have $199 tier

Your PDF includes:

• An external review request drafted under ACA section 2719
• A state DOI cover sheet with the mailing address for your state
• A NAIC-model checklist so nothing is missing

Use those as-is. Attach the required documents.

If you have $49 or $99 tier

Email support with your appeal ID and we will supply the external review packet at the difference in cost, or you can upgrade. See How to request a refund.

Timing after you file

• Standard external review: the reviewer must decide within 45 days
• Expedited external review (if delay would seriously jeopardize your health): 72 hours
• The plan is bound by the external reviewer's decision. If reversed, the plan must comply

Expedited external review

You can request expedited external review at the same time as (or in place of) an expedited internal appeal if your health could be seriously jeopardized by waiting. Note "URGENT" clearly on the request and ask for expedited handling.

What happens if you win

• The plan must reprocess the claim and pay according to plan terms
• You may need to submit the reprocessing request separately (some plans do it automatically)
• Follow up if payment does not arrive within 30 days of the reversal

What happens if you lose

The external reviewer's decision is binding on the plan. It is not binding on you in the sense that you can still sue under ERISA if the plan is ERISA-governed. But the external review record is now part of the file the court will see, so a loss at external review is a headwind.

When to hire an attorney

If external review is denied and the dollar amount is high, or if the plan will not comply with a reversal, an ERISA attorney can enforce the decision. See When to hire an ERISA attorney.