External review is your right to have an independent medical expert — with no ties to your insurance company — review your denial. Under the ACA, decisions are binding on the insurer. This is often the most powerful step in the appeal process.
When Is External Review Available?
External review is available for:
- Medical necessity denials
- Experimental or investigational treatment denials
- Rescission (plan cancellation) decisions
- Some states extend coverage to other denial types
Prerequisites
- Internal appeals must be exhausted (typically)
- Exception: If the insurer failed to follow proper appeal procedures
- Exception: If the insurer agrees to expedited external review
- Must be filed within the deadline (typically 4 months from final internal denial)
How to File
Federal External Review (Self-Funded Plans)
- Contact your plan to request external review
- The plan forwards to a federally-accredited Independent Review Organization (IRO)
- No cost to you
State External Review
- Contact your state's insurance department
- Fill out the external review request form
- Submit supporting documentation
- The state assigns an IRO
What Happens During Review
- IRO receives all medical records and appeal documentation
- An independent physician specialist in the relevant field reviews the case
- Reviewer examines: clinical evidence, insurer's criteria, your documentation
- Standard decision: Within 45 days
- Expedited decision: Within 72 hours
- Decision is communicated to you and the insurer
- Binding: Insurer must comply with reversal decisions
Maximizing Your Chances
- Submit the most comprehensive evidence package possible
- Include a detailed specialist letter (not just your PCP)
- Reference specific clinical guidelines and peer-reviewed studies
- Address each criterion the insurer cited for denial
- Organize your documentation clearly with a table of contents