My claim was denied
Can someone outside my plan look at my denial?
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An external review is a second look at a denial by an independent reviewer who does not work for your plan. You can ask for one after the plan's final internal denial, and the plan must follow the result.
What to do
- Check that your denial qualifies: it involves medical judgment (like medical necessity), calls the care experimental, or cancels your coverage, and the plan's internal appeals are finished.
- Find the instructions in the final denial letter. Some states run the review; otherwise the federal process is used.
- File within the deadline on the letter, usually 4 months after the final internal decision, and send everything: the denials, your appeal, the doctor's letters and any new records.
- Ask for an expedited (fast) review if waiting would put your health at serious risk.
What to say
I'm requesting an external review of this final denial. Can you tell me whether this goes through the state or the federal process, and confirm the deadline?
Ask the plan first and, if the answer is vague, ask your state insurance department.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Missing the deadline because you were waiting for the plan to offer it. The plan does not file for you; the letter tells you how, and the clock runs from that final denial.
Better done together
We’re here to help
An external review can turn a denial around, but the request and the papers have to be right. We help you check whether you qualify, meet the deadline, and send what the independent reviewer needs.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
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The rule behind it
The Affordable Care Act gives most people with private plans the right to an external review after the plan's final internal denial. An independent review organization decides. You usually have 4 months to ask, and the plan must accept the decision. Fast reviews are decided within 72 hours. Medicare and Medicaid have their own appeal steps.
Sources
- HealthCare.gov — External review
- HealthCare.gov — Internal appeals
- Your final denial letter and your plan's Evidence of Coverage
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.