How to request an independent external review of a denied claim

Can I get someone outside my insurance company to look at my denied claim?

Often, yes. You are not alone in wondering this. Most people who get a denial letter do not know there is a step beyond the insurer's own appeal.

An independent external review sends your denied claim to a reviewer who does not work for your health plan. It covers denials that involve medical judgment, where you or your doctor disagree with the plan, denials that call a treatment experimental or investigational, and cancellations of coverage the insurer says were based on false or incomplete information.

The steps on this page are for private health insurance, such as job-based and Marketplace plans. Medicare has its own appeal process, and Medicaid and separate dental-only plans can have different rules too. Your denial letter should say what your review rights are, so check it first.

How do I ask for an external review? What are the steps?

The exact form depends on your plan type and your state. These four steps fit most people with private health insurance.

• Step 1: Finish the internal appeal. Ask your insurer to appeal its own decision first. You generally have 180 days (6 months) from the denial notice to file it. In urgent situations you can ask for an external review before the internal appeal is finished, or file both at the same time.
• Step 2: Read your final denial letter. It should say which outside process applies to you, where to send the request, and the date your deadline starts.
• Step 3: File the request in writing. Use the state or federal process named in your letter. For the federal process, you can use the online portal, mail, fax or email, and you can call 1-888-866-6205 for help. You can also appoint someone to file for you, such as your doctor.
• Step 4: Send your paperwork and wait. Include the denial letters, your doctor's notes, and anything that explains why you need the care. A standard review is decided no later than 45 days after the request is received, and an expedited (urgent) one no later than 72 hours.

How long do I have to request an external review?

You generally have 4 months from the date you receive the denial notice or the final internal appeal decision to file a written request. The date and instructions in your own letter are the ones to trust, so check them.

If the clock is close to running out, file first and gather extra paperwork afterward where the process allows it.

Does my plan type and state matter?

Yes, a lot. Insurance companies in all states must offer an external review process that meets federal consumer protection standards. If your state has its own process, your insurer follows it. If your state's process does not meet the minimum standards, the federal Department of Health and Human Services oversees the process for insurers in your state.

Employer plans that are not subject to state law, including newer self-insured employer plans, are covered by the federal standards. Older plans that kept grandfathered status and retiree-only plans may not follow these same rules.

If you have Medicare, follow the appeal steps on your Medicare notice instead: the plan must tell you in writing how to appeal. For any plan, your denial letter, your plan's member services line, or your state insurance department can tell you which process applies to you.

What happens after I ask, and does the insurer have to follow the decision?

The reviewer either upholds the insurer's decision or rules in your favor. Your insurer is required by law to accept the reviewer's decision. For the federal process, the decision is final and binds both you and the plan, except where you have other options under federal or state law, such as a lawsuit.

If the reviewer sides with you, the plan is expected to pay for the benefit it denied. If they do not, ask your state insurance department what options are left.

Does an external review cost money?

If your plan uses the federal process run by HHS, there is no charge to you. Otherwise, the charge cannot be more than $25 per external review.

Confirm any fee when you file.

Your checklist

• Find the date on your final denial letter and write down your deadline
• Finish (or start) the internal appeal with your insurer
• Check the letter for which outside review process applies to you
• Ask your doctor to write a short note on why you need the care
• Gather denial letters, bills and medical records in one folder
• File the request in writing and keep a copy and proof of sending
• Mark your calendar for 45 days (72 hours if urgent)

A letter you can copy

[Date] [Name of your external review process, from your denial letter, or "External Review Request"] [Address or portal from your denial letter] Re: Request for independent external review Name of patient: [Your full name] Member ID: [ID from your insurance card] Claim or reference number: [Number from denial letter] Date of final denial: [Date on letter] Service or treatment denied: [What was denied] I am asking for an independent external review of the decision to deny the service above. My plan's reason for the denial was: [reason given in the letter]. I disagree because: [one or two plain sentences, for example: my doctor says this care is needed for my health]. I have attached: [denial letters, doctor's note, medical records, bills]. [If urgent: Waiting could seriously harm my health, so I am asking for an expedited review.] [If someone is filing for you: I authorize [name] to act for me in this review.] Please confirm that you received this request. Sincerely, [Your name] [Phone] [Address]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• How to write an insurance appeal letter
• What your doctor should put in a letter of medical necessity
• How to read an insurance denial letter
• Internal appeal vs external review: what is the difference?
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.