External Review Process: Your Last Resort for Denied Claims

External review is your final level of appeal — an independent third party reviews your case and makes a binding decision. If your internal appeals have been denied, external review gives you one more shot at getting your claim covered.

What Is External Review?

External review is a process where an independent reviewer (not employed by your insurance company) examines your claim denial. Key facts:

  • The reviewer's decision is binding on the insurer — if they rule in your favor, the insurer must cover the service
  • Available under the ACA for most health plans
  • Free to the consumer
  • Typical timeline: 45 days for standard review, 72 hours for expedited

When Can You Request External Review?

You can request external review when:

  1. Your internal appeals have been exhausted (or you've waited past the insurer's response deadline)
  2. The denial involves medical judgment (medical necessity, experimental treatment)
  3. The denial involves a rescission of coverage

How to File

Step 1: Confirm Eligibility

Check your final internal denial letter — it should include information about your external review rights.

Step 2: Submit Your Request

Contact your state insurance department or the federal external review process (for self-insured plans).

Step 3: Prepare Your Case File

Include:
  • All denial letters and appeal correspondence
  • Medical records
  • Physician letters of medical necessity
  • Clinical evidence and guidelines
  • Any new information not previously considered

Step 4: Wait for the Decision

Standard reviews take up to 45 days. Expedited reviews (for urgent situations) take up to 72 hours.

Success Rates

External review success rates vary by state and type of denial:

  • Medical necessity denials: 40-55% overturn rate
  • Experimental treatment denials: 30-45% overturn rate
  • Overall average: approximately 40% of external reviews favor the patient

State-Specific Resources

Each state has its own external review process. Contact your state insurance commissioner's office for specific procedures and forms.

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Frequently Asked Questions

Is external review free?

Yes, external review is free for consumers under the Affordable Care Act. The insurance company pays for the independent review. You should never be charged a fee to request an external review of your claim denial.

Is the external review decision final?

The external review decision is binding on the insurance company — if the reviewer rules in your favor, the insurer must cover the service. However, you may still have the right to pursue legal action if you disagree with an unfavorable decision.

How long does external review take?

Standard external reviews typically take up to 45 days. If your situation is urgent (ongoing treatment, serious health risk), you can request an expedited review, which must be completed within 72 hours.

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