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.
• Internal Appeals
• What kinds of denials can be appealed?
• Types of denials that can go to external review
• How much does an external review cost?