External Reviews

External Reviews

Sat, 02/15/2020 - 18:22

A review of an insurer's decision to deny coverage for or payment of a service by an independent third-party not related to the insurance company.

If the insurer denies an appeal, an external review can be requested.

• In urgent situations, an external review may be requested even if the internal appeals process isn't yet completed.

♦ An external review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for cancellation of coverage.

An external review either upholds the insurer's decision or overturns all or some of the insurer’s decision. The insurer must accept this decision.

Related content


• Internal Appeals

• What kinds of denials can be appealed?

External Review

• Types of denials that can go to external review

• How much does an external review cost?