How to request external review

To ask for external review, read your final denial letter to see which process applies, then send a written request to the address or portal it gives, with your evidence, within four months of receiving the letter. Keep proof that you sent it. If your health could be seriously harmed by waiting, say so and ask for an expedited review.

What this means

External review is a review by someone outside your plan. Which office receives your request depends on your plan and state. See how external review works for the three routes. In some states you file with the state insurance regulator. In others you file with your insurer, which passes the case on. Under the federal process run by the Department of Health and Human Services (HHS), you can file directly through its contractor. Your final denial letter is the place to start, because it must explain how to begin external review.

What to do

1. Read your final denial letter. Find the sentence on external review. Note the address, portal, form and phone number. Mark the date you received it. The date on your notice controls.
2. Confirm that your denial qualifies. Denials involving medical judgment, surprise-billing protections or rescission qualify under the federal process. A denial that you are not eligible for the plan does not. If the plan says your denial does not qualify, ask who decided and on what basis. The reviewer, not the plan, decides whether medical judgment is involved.
3. Check your deadline. You must be allowed at least four months from receiving the denial or final internal denial. If you are not sure which kind of plan you have, use four months from the date of the final denial letter. For retiree coverage from a former employer, ask the plan administrator whether your retiree plan is an employer plan. Under the federal process, a deadline that falls on a weekend or federal holiday moves to the next business day. Do not wait until the last day. Use the decision clock.
4. Gather your evidence. Collect the denial letters, your claim file, your doctor’s letter, medical records and any studies or guidelines that support the care. See how to ask your doctor for a letter and how to find guidelines and studies.
5. Fill out the request. Use the plan’s or state’s form if there is one. If not, the external review request letter works. Give your name, member number, claim number, the care denied, and why you disagree. Use the external review planner to find your route.
6. Sign the request and ask about a records release. Ask the plan or the regulator whether a signed form is needed so the reviewer can get records from your providers, and include it if so.
7. Send it and keep proof. Choose a method that gives you a record: portal receipt, fax confirmation or certified mail. Keep a full copy. Ask your plan and your doctor’s office to keep their copies.
8. Watch the early steps. Under the federal process the plan has 5 business days to do a preliminary eligibility check and 1 more business day to tell you the result. If your request is incomplete, you may fix it within the four-month period or 48 hours, whichever is later.
9. Send more evidence if you have it. Under the federal process you have at least 10 business days after the reviewer’s notice to add information. Under state processes the minimum is 5 business days.

Asking for a fast decision

If waiting for a standard review would seriously jeopardize your life, health or ability to regain maximum function, ask for expedited external review. You can ask while an expedited internal appeal is still pending, and you can also ask after a final internal denial about an admission, availability of care, a continued stay, or emergency services when you have not left the hospital. An expedited decision is due as fast as the medical situation requires and no later than 72 hours. Use the expedited external review letter. Ask your doctor to describe the urgency in a short letter. See how to get an expedited appeal.

What the plan may say, and what to say back

“You haven’t finished our internal appeal.” Exhaustion is not required if the plan waives it, if the plan failed to follow the appeal rules, or if you ask for expedited review alongside an expedited internal appeal. See when the plan misses its deadline.

“We cannot find your request.” Send the proof of delivery and ask the plan to confirm the date it received the request in writing. Under the federal process, if the plan misses its 5-business-day deadline to send its file to the reviewer, the reviewer may end the review and reverse the denial.

“Your request is incomplete.” Ask exactly what is missing and send it right away. You have the four months or 48 hours, whichever is later, to fix it.

The rule

A claimant must be allowed at least four months after receiving a denial or final internal denial to request external review. A standard external review decision is due within 45 days after the reviewer receives the request. An expedited decision is due as quickly as the medical situation requires and no later than 72 hours. See title 29 of the Code of Federal Regulations (CFR), section 2590.715-2719(c)(2) and (d).

Watch for

• The federal government’s own process. If your plan uses the HHS-administered process, you can file online, by mail, by fax or by email, or call the information line at 1-888-866-6205. Two official pages list different portal addresses, so use the one in your denial letter or get it by phone. Confirm that the process is open before a deadline.
• Cost. The federal processes are free. A state fee, where one is allowed, may not exceed $25. See your state page, listed under all states.
• Self-funded employer plans. They use the federal process through private accredited reviewers. See external review for self-funded employer plans.
• A complaint is not a request. Telling a regulator about your plan does not start external review.

What next

• What to expect from an external review decision: timing, notices and what happens if the reviewer agrees or disagrees.
• How to get an expedited appeal: for the fast route at the internal step.
• After a final denial: every option left: if external review does not go your way.