An external review is an independent evaluation of your insurance company's decision to deny coverage for a service, treatment, or claim. It's your right to have someone outside your insurance company take a second look when you believe a denial was wrong.
Here's how it works: if your internal appeal (the one handled by your insurer) doesn't go your way, you can request an external review. An independent third party, not connected to your insurance company, reviews your case, including your medical records and the reason for denial. Their decision is binding, meaning your insurer must follow it.
Under the ACA, all Marketplace plans and most employer plans must offer external review. You typically have four months after receiving a final internal appeal denial to request one. The review must be completed within 45 days, or faster for urgent cases (as quickly as 72 hours if a delay could seriously harm your health).
External reviews are especially valuable when your insurer denies coverage by calling a treatment "not medically necessary" or "experimental." An independent medical reviewer with relevant expertise evaluates whether the treatment is appropriate for your situation.
There's no cost to you for requesting an external review. It's a consumer protection built into the ACA specifically so insurance companies don't get the final word on your care.
Generally, yes. you need to go through your plan's internal appeal process first. However, if your case is urgent or your plan failed to follow proper appeal procedures, you may be able to skip directly to external review.
Your insurance company must comply with the reviewer's decision. If the reviewer overturns the denial, your plan must cover the service or treatment as if it had been approved from the start.
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