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External review: how an independent reviewer can overturn your insurer

External review sends your denial to an independent review organization with no financial relationship to your plan. Their decision binds the insurer. It is usually free to you, it runs on a fixed timeline, and it is the single most effective step available on a medical-necessity denial.

Applies to Non-grandfathered plans. Availability and route differ for self-funded plans; check your denial letter.

What to do

  1. Confirm you have exhausted the internal appeal

    External review normally comes after the plan's own process, unless deemed exhaustion applies.

  2. File within the deadline on the final denial

    Federal external review must be requested within four months of receiving the denial, under 29 CFR 2590.715-2719(d)(2)(i). State processes may differ, so use the deadline on your final denial.

  3. Send everything, not a summary

    The reviewer sees the record you submit. Clinical letters, the plan's own criteria, your correspondence log, and the denial letters all belong in the file.

  4. Ask for expedited review where delay causes harm

    Expedited external review exists and runs in days rather than weeks.

  5. Write to the criteria, not to sympathy

    The reviewer is a clinician applying a standard. Show that the standard is met.

Who the reviewers are

Independent review organizations are contracted entities, not insurer departments. Names you may see on correspondence include IPRO, MAXIMUS, and MCMC. Your denial letter or state insurance department will say which one handles your review.

Common questions

Does external review cost me anything?
Generally no, or a nominal fee. Your denial letter and your state insurance department can confirm.
What if the insurer ignores the decision?
The decision binds the plan. If it is not honoured, that is a complaint to your state insurance department, or to the Department of Labor for a self-funded plan.

Where to go next

Sources for the legal points on this page

The ACA appeal framework: internal appeal, then binding external review

Federal — non-grandfathered group health plans and issuers · effective in force

29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment

Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06

Last updated 2026-08-06Not legal or medical advice