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.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. When your plan has upheld its denial on appeal, or has not followed the appeal rules, and the denial turns on a medical judgment or on No Surprises Act protections. For job-based and individual plans, your plan must give you at least four months from the day you received the final denial; check the date on your notice, which controls. This right does not apply to grandfathered plans (except for surprise-billing denials), short-term plans or fixed indemnity plans. Your denial notice should say whether external review is offered. A denial that says you are not eligible for the plan is generally not reviewable this way.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address for external review requests, from your final denial letter or your state regulator]
Re: Request external review Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am asking for an independent external review of my plan's final decision dated [Date on the final denial notice], which refused [The care or drug that was denied]. The claim number is [Claim or reference number], and the date of service or request was [Date of the care].
My plan, [Name of the health plan], first denied this on [Date on the denial notice]. The reason given was: [The reason the plan gave]. I am making this request on or before the deadline stated in my final denial notice.
I believe the plan was wrong because: [Why you believe the plan was wrong, in your words]
I ask that you: 1. Confirm in writing that you received this request, and tell me the date you received it. 2. Complete your eligibility check and send my request to an independent review organization without delay. 3. Send the reviewer my complete claim file, including the clinical criteria the plan used. 4. Send me a copy of everything you send to the reviewer, free of charge.
I understand the reviewer looks at my claim fresh and that I may send more information. Please tell me the date by which I must send it and where to send it. I ask for the decision in writing. If the reviewer reverses the denial, I ask that you provide coverage or payment immediately.
Enclosures: 1. Copy of the final denial notice 2. Copy of your first denial notice and your appeal letter 3. Letter from your doctor, if you have one 4. Medical records that support the request
Sincerely, [Your name]
Before you send it
Send it where your final denial notice tells you to ask for external review. That is the plan, the insurer or a state office, depending on your state and your plan. If your plan uses the federal process run by the federal government's contractor, the information line is 1-888-866-6205, and HealthCare.gov's external review page lists how to file. Send it by a method that gives you proof of the date, and keep a copy.
What to enclose
- Copy of the final denial notice
- Copy of your first denial notice and your appeal letter
- Letter from your doctor, if you have one
- Medical records that support the request
What happens next
- Under the federal process the plan checks within 5 business days whether your request qualifies, and tells you within 1 more business day. If your request is incomplete, you have the later of the four-month period or 48 hours to fix it.
- You may send the reviewer more information. The time allowed is at least 10 business days after the reviewer's notice under the federal process, and at least 5 business days under a state process. Send it early.
- A standard external review decision is due within 45 days after the reviewer receives your request. If waiting could seriously harm your health, use the expedited external review letter instead, which is decided within 72 hours.
- The federal process is free. A state process may charge a fee only if state law allowed it as of 18 November 2015. Any such fee is capped at $25, refunded if you win and waived for financial hardship.
- If the reviewer decides for you, the plan must provide coverage or payment immediately, even if it plans to ask a court to review the decision. The decision binds the plan and you, except where other remedies exist under state or federal law.
- For job-based and individual plans, your deadline is at least four months from the day you received the final denial. Check the date on your notice, which controls.
- If you are writing for someone else, tick "I am writing for someone else". The office you are writing to may require its own authorization form. See the letter "Name someone to act for you".