External Health Insurance Appeal / Independent Review Request

Instructions for Use

External review is an independent review of your health insurance company's denial by a qualified third party (Independent Review Organization or IRO). This is your right under the Affordable Care Act after exhausting internal appeals.

Eligibility for External Review:
- Denial based on medical necessity
- Denial based on appropriateness
- Denial based on health care setting
- Denial based on level of care
- Denial based on effectiveness of covered benefit
- Denial that service is experimental/investigational
- Rescission of coverage

Key Points:
- Must exhaust internal appeals first (unless plan failed to follow procedures)
- File within 4 months (120 days) of final internal appeal denial
- IRO decision is binding on the insurance company
- Free or maximum $25 fee (refunded if you win)

External Review Request

[Date]

VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED
[Also submit to state insurance department if using state process]

[Insurance Company Name]
[External Review/Appeals Department]
[Street Address]
[City, State, ZIP]

REQUEST FOR EXTERNAL REVIEW / INDEPENDENT REVIEW

Re: External Review Request Following Final Internal Appeal Denial

Dear External Review Department:

Pursuant to my rights under the Affordable Care Act (45 CFR 147.136), state insurance law, and my health plan, I hereby request an external review of the final adverse benefit determination issued by [Insurance Company Name] on [DATE OF FINAL DENIAL].

My internal appeal was denied on [DATE], and I am now exercising my right to have this decision reviewed by an Independent Review Organization (IRO).

Section 1: Eligibility Confirmation

Confirming Right to External Review

Type of Plan:
☐ Individual health insurance plan
☐ Employer-sponsored group health plan (fully insured)
☐ Employer-sponsored group health plan (self-insured/ERISA)
☐ ACA Marketplace plan
☐ COBRA continuation coverage
☐ Other: ______________________________________________

Basis for External Review Eligibility (Check all that apply):

☐ Denial based on medical necessity
☐ Denial based on appropriateness of care
☐ Denial based on health care setting
☐ Denial based on level of care
☐ Denial based on effectiveness of covered benefit
☐ Denial that service is experimental/investigational
☐ Rescission of coverage
☐ Plan failed to follow internal appeal procedures (deemed exhaustion)

Section 2: Internal Appeal Exhaustion

Documentation of Internal Appeal Process

First Level Internal Appeal:

Second Level Internal Appeal (if applicable):

Final Internal Appeal Denial:

Deemed Exhaustion (If Internal Appeal Not Completed)

☐ I am requesting external review without completing internal appeals because:

☐ The plan failed to comply with internal appeal requirements under 45 CFR 147.136
☐ The plan failed to provide timely decision (30/60/72 hours)
☐ The plan failed to provide required notices
☐ This is an urgent situation requiring immediate external review
☐ Other: ______________________________________________

Section 3: Summary of Denial

Original Claim and Treatment Information

Reason for Final Denial

Plan's Stated Reason:

☐ Not medically necessary
☐ Experimental/investigational
☐ Not appropriate setting/level of care
☐ Treatment not effective for condition
☐ Does not meet clinical criteria
☐ Out of network (without medical necessity exception)
☐ Other: ______________________________________________

Exact Language from Final Denial Letter:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Section 4: Urgency Determination

Request for Expedited External Review

☐ I REQUEST EXPEDITED EXTERNAL REVIEW (72-hour decision)

Expedited review is available if:
☐ Standard timeframe would seriously jeopardize my life
☐ Standard timeframe would seriously jeopardize my health
☐ Standard timeframe would jeopardize my ability to regain maximum function
☐ This involves admission, availability of care, continued stay, or health care service for which I received emergency services and have not been discharged

Physician Certification of Urgency:

Physician Statement:

"I certify that applying standard external review timeframes could seriously jeopardize the life or health of the patient, or the patient's ability to regain maximum function."

Physician Signature: __________________________ Date: ______________

☐ Standard External Review - 45-day timeframe acceptable

Section 5: Medical Condition and Treatment

Patient's Medical Condition

Primary Diagnosis:

_______________________________________________________________________________

Secondary/Related Diagnoses:

_______________________________________________________________________________

Medical History Relevant to This Claim:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Treatment Being Requested

Description of Treatment/Service:

_______________________________________________________________________________

_______________________________________________________________________________

Why This Treatment is Medically Necessary:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Alternative Treatments Already Tried:

Consequences of Not Receiving This Treatment:

_______________________________________________________________________________

_______________________________________________________________________________

Section 6: Arguments for Reversal

Why the IRO Should Overturn the Denial

Medical Necessity Arguments:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Clinical Guidelines and Evidence Supporting Approval:

☐ Attached peer-reviewed medical literature
☐ Attached clinical practice guidelines
☐ FDA approval documentation
☐ Medicare coverage determinations
☐ Specialty society recommendations

Specific Citations:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

Errors in Plan's Review:

☐ Reviewer lacked appropriate specialty expertise
☐ Reviewer did not consider all submitted information
☐ Plan applied incorrect criteria
☐ Plan's criteria conflict with accepted medical standards
☐ Other: ______________________________________________

Section 7: Documentation Submitted

Documents Included with External Review Request

Denial Documentation:
☐ Original claim denial letter
☐ First level internal appeal denial
☐ Final internal appeal denial letter
☐ All Explanation of Benefits (EOBs)
☐ Correspondence with insurance company

Medical Documentation:
☐ Letter of Medical Necessity from treating physician
☐ Relevant medical records
☐ Test results (labs, imaging, pathology)
☐ Treatment history
☐ Hospital records (if applicable)
☐ Specialist consultation reports

Supporting Evidence:
☐ Peer-reviewed medical literature
☐ Clinical practice guidelines
☐ FDA documentation
☐ Medicare coverage policies
☐ Other clinical evidence

Authorization:
☐ Authorization for Release of Medical Information (signed)
☐ Designation of Representative (if applicable)

Section 8: Authorization for Medical Information Release

HIPAA Authorization

I authorize [Insurance Company Name] and the assigned Independent Review Organization to obtain and review any medical records, test results, physician notes, and other health information necessary to conduct this external review.

This authorization includes records from:

This authorization expires upon completion of the external review process or one year from the date signed, whichever is earlier.

Patient Signature: ______________________________________________

Date: ______________________________________________

Section 9: Representative Designation (If Applicable)

Appointment of Authorized Representative

☐ I am submitting this request on my own behalf

☐ I appoint the following person to act as my representative:

Patient Signature (authorizing representative): ______________________________________________

Representative Signature (accepting appointment): ______________________________________________

Date: ______________________________________________

Section 10: Contact Information

Member/Patient Contact:

Treating Physician Contact:

Section 11: Member Certification

I certify that:
- The information provided is true and accurate to the best of my knowledge
- I have exhausted my internal appeal rights (or am entitled to deemed exhaustion)
- I understand the IRO's decision will be binding on the insurance company
- I authorize release of medical information for this review

Member Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

External Review Process Information

What Happens Next

1. Acknowledgment - Plan/state will acknowledge receipt within 5 business days
2. IRO Assignment - Case assigned to Independent Review Organization
3. Record Review - IRO reviews complete claim file and medical records
4. Medical Expert Review - Clinical reviewer with appropriate expertise reviews case
5. Decision - IRO issues binding decision (45 days standard / 72 hours expedited)
6. Notification - You and insurance company receive written decision

IRO Decision is Binding

• If IRO reverses denial, insurance company must provide coverage
• If IRO upholds denial, you may have additional legal remedies
• IRO decision is final for purposes of external review

Costs

• HHS-Administered Process: Free
• State Process: Free or maximum $25
• Fee Refund: If you win, any fee paid is typically refunded or deducted from amount owed

State Insurance Department Contact

If your state administers its own external review process, also file with:

Tracking

Resources

• Healthcare.gov External Review: https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
• CMS External Review: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts
• State Insurance Departments: https://content.naic.org/state-insurance-departments
• Consumer Assistance Programs: https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants

This template is provided for informational purposes only and does not constitute legal advice. Consult with a healthcare attorney for specific legal guidance.