Federal agency ยท Centers for Medicare & Medicaid Services
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.
Know before you go
It is free, and the reviewer's decision binds the plan. It covers denials that turn on medical judgment (such as medical necessity or an experimental or investigational finding) and cancellations of coverage, but not a finding that you are not eligible for the plan. It applies only if your state or plan uses this process; many states run their own. The most common mistake is to go here first: your final denial letter says which reviewer to contact. The request is due within four months after you receive the notice; check the date on your notice, which controls.
- Cost
- No cost to you, your authorized representative or the plan, according to the page.
- Where
- Nationwide
- How to start
- Check your final denial letter for the reviewer it names. If it names the federal process, ask for the request form on the information line, or use the secure online portal, fax, mail or email shown on the HealthCare.gov external review page.
- Phone
- 1-888-866-6205, as printed on the provider's page
- Have ready
- Your final denial letter from the plan; The original denial notice; Your doctor's letter and records; A signed form naming a representative, if someone files for you
Where this comes from
- Provider
- Centers for Medicare & Medicaid Services
- Source we read
- https://www.cms.gov/cciio/programs-and-initiatives/consumer-support-and-information/csg-ext-appeals-facts
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid 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
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy