Appealing a health plan decision
There are 2 steps in the external review process:
You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim has been denied.
External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.
Types of denials that can go to external review
Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
Any denial that involves a determination that a treatment is experimental or investigational
Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage
What are my rights in an external review?
Insurance companies in all states must offer an external review process that meets the federal consumer protection standards.
State: Your state may have an external review process that meets or goes beyond these standards. If so, insurance companies in your state will follow your state’s external review processes. You’ll get all the protections outlined in that process.
Federal: If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.
Depending on your plan and where you live, the following may apply to you:
- In states where the federal government oversees the process, insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations.
- If your plan doesn’t participate in a state or HHS-Administered Federal External Review Process, your health plan must contract with an independent review organization.
How do I learn more about my state’s external review?
- Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It’ll give you the contact information for the organization that will handle your external review.
- See this state list maintained by the HHS’s Center for Consumer Information & Insurance Oversight.
How long does external review take?
Standard external reviews are decided as soon as possible – no later than 45 days after the request was received.
Expedited external reviews are decided as soon as possible – no later than 72 hours, or less, depending on the medical urgency of the case, after the request was received.
If my health insurance company participates in the HHS-Administered Federal External Review Process, how do I request an external appeal?
- Visit externalappeal.cms.gov. You’ll be able to file a request using a secure website. For claimants who are able to do so, the portal is the preferred method of submission for review requests.
- Call toll free: 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.
- Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
- Submit a request via email: is email@example.com
Can someone file an external review for me?
You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf. An authorized representative form is available at: externalappeal.cms.gov
How much does an external review cost?
If your health insurance company is using the HHS-Administered Federal External Review Process, there’s no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can’t be more than $25 per external review.
Where can I get help filing an appeal?
If you need help filing an internal appeal or external review, your state’s Consumer Assistance Program (CAP) or Department of Insurance may be able to help you. Contact us for more information.