External review is your right to have an independent third party — not affiliated with your insurance company — review your denial. Under the ACA, most health plans must provide access to external review. This guide explains exactly how it works.
What Is External Review?
External review (also called independent medical review in some states) is a process where:
- An independent reviewer examines your case
- The reviewer has no financial ties to your insurer
- The reviewer specializes in the relevant medical area
- The decision is binding on the insurer (in most states and for ACA plans)
Eligibility
External review is available for:
- Medical necessity denials
- Experimental or investigational treatment denials
- Rescission (plan cancellation) decisions
- Some states extend to other denial types
How to File
- Exhaust internal appeals first (or insurer failed to follow procedures)
- File within the deadline (typically 4 months from final internal denial, varies by state)
- Submit to your state's external review program or the federal program
- Include all supporting documentation
- No cost to you
What Happens Next
- Your state or the federal program assigns an Independent Review Organization (IRO)
- The IRO reviews all medical records, the insurer's decision, and your arguments
- Standard decision: Within 45 days
- Expedited decision: Within 72 hours (for urgent cases)
- If the IRO overturns the denial, the insurer must comply
Tips for External Review Success
- Submit the strongest possible evidence package
- Get a detailed medical necessity letter from your specialist
- Include peer-reviewed studies
- Reference specific clinical guidelines
- Address each reason for the denial