External review request

Find the date on your final denial letter and count four monthsYou must be allowed at least four months after you receive the final internal denial to request external review, and the date on your notice controls.Check the final denial letter for the process and formYour letter should say how to ask: an insurer usually uses its state process, a self-funded employer plan uses the federal process through a private independent review organization, and where a state has no qualifying process the process run by the federal Department of Health and Human Services (HHS) may apply.Check that your reason qualifiesThe federal process covers denials that involve medical judgment (such as medical necessity or experimental treatment), denials about surprise-billing protections, and rescissions of coverage, but not a finding that you are not eligible for the plan.Check whether you must finish the internal appeal firstYou do not if the plan waives it, if the plan failed to follow the internal appeal rules, or if you ask for expedited external review at the same time as an expedited internal appeal.

Use the request form named in your final denial letter or by your state regulatorYour state insurance department or the HHS-administered portal publishes the form, and the letter should say which applies.Ask your doctor for a letter supporting the treatmentThe reviewer considers your medical records, your treating professional's recommendation, the plan terms and evidence-based practice guidelines.Attach the final denial letter, your appeal and your recordsThe reviewer looks at your claim fresh and is not bound by the plan's earlier decisions, so the file should show everything.Name an authorized representative if someone files for youThe federal portal has an appointment of representative form for this.Do not pay a fee unless your state allows oneThe federal process and the HHS-administered process are free, and a state fee may be charged only where state law authorized it by 18 November 2015, with a cap of $25 per review and $75 per plan year, waived for financial hardship.

Send it so you can prove the dateThe HHS-administered process takes requests by online portal, mail, fax or email, and its information line is 1-888-866-6205.Watch for the plan's eligibility checkThe plan must complete a preliminary check within 5 business days and tell you within 1 more business day, and if your request is incomplete you can fix it within the four-month period or 48 hours, whichever is later.Send extra information when the reviewer asksYou have at least 10 business days after the reviewer's notice under the federal process, and at least 5 business days under a state process.Write down the decision dateA standard decision is due within 45 days after the independent review organization receives the request.

Ask for an expedited external reviewA fast decision is due as quickly as your medical situation requires and no later than 72 hours.Ask at the same time as an expedited internal appealYou can do this when waiting for the internal appeal would seriously jeopardize your life, health or ability to regain maximum function.Know the extra case: a stay or emergency care not yet dischargedExpedited external review is also available after a final internal denial that concerns an admission, availability of care, a continued stay, or emergency services when you have not been discharged.

Read the written decision and keep a copyThe decision binds the plan and you, except to the extent other remedies are available under state or federal law.If the reviewer sides with you, ask the plan in writing for the date it will pay or cover the careThe plan must provide coverage or payment immediately and without delay, even if it intends to seek court review.If the reviewer upholds the denial, look at what is leftYou may still complain to your regulator or, for an employer plan, consider a lawsuit, and a lawyer or a free advocate can help you decide.

External review request

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