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.
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
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:
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.
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
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.