External review request letter for a health plan denial

Your plan turned down your internal appeal. You can often take your case to an independent review organization next. It isn't part of your plan, and your plan must accept its decision. Our guide to external review for health insurance explains how the steps fit together.

When to use this letter

Use it after your plan's final denial, when the denial involves medical judgment. That includes:

• Whether the care was medically necessary
• The level of care or the setting, like inpatient or outpatient
• Whether a treatment is experimental or investigational
• A plan cancelling your coverage because it says your application was wrong or incomplete

You usually finish the internal appeal first. Our insurance appeal letter covers that step. In urgent situations, you can file both at the same time.

Medicare, Medicare Advantage, and Medicaid use their own appeal systems. If you have 1 of those, follow the steps on your notice. Our guide on how to appeal an insurance denial explains the differences.

Check your deadline and where to send it

You have 4 months from the date you get the final denial. Our appeal deadline calculator can help you count.

Your final denial letter or explanation of benefits (EOB) gives the contact for your review. It may be your plan, your state, or the federal process. Some processes have their own form. If yours does, fill it out and attach this letter.

What to fill in

• Review contact and address: copy them from your final denial letter.
• Denial reason: use the words from the final denial.
• New evidence: list anything your plan didn't see, like a new letter from your doctor. If there's nothing new, write "None."
• The urgent paragraph: keep it only if your doctor believes waiting could seriously harm your health. If not, delete the paragraph that starts "Urgent request."

What to attach

Send copies, not originals. Include:

• The final denial letter
• Your internal appeal and anything you sent with it
• A letter from your doctor that answers the denial reason
• Any new records, like test results or notes

How to send it

Use the method your final denial letter gives. The federal process takes requests online, by fax, or by mail, and HealthCare.gov lists the details.

• By mail: use certified mail with a return receipt, so you have proof of the date.
• Online or by fax: save the confirmation page or fax receipt.
• Either way: keep a copy of everything you send.

Tell the provider's billing office you've asked for an external review. Ask them to hold the bill while you wait, and note the date and the person's name.

What happens next

A standard external review is decided within 45 days after the request is received. An expedited review is decided within 72 hours or sooner, depending on how urgent your case is.

If the reviewer sides with you, your plan must accept the decision. Check your next explanation of benefits and bill to make sure the claim was paid. If you were denied care before you got it, see what to do when prior authorization is denied.