External review: how an independent reviewer can overturn your insurer

This is the most common way a plan keeps an out-of-network denial out of external review. External review covers determinations involving medical judgment, so a plan that calls yours a pure benefits decision is arguing you have no route.

The regulation answers this directly, in a worked example. Under 29 CFR 2590.715-2719(d)(1)(ii), Example 2, a plan covers out-of-network services only where the service cannot effectively be provided in network, a member seeks a specialised procedure out of network, and the plan denies it because the provider is out of network. The regulation's own conclusion is that the denial "is based on whether a service can effectively be provided in network and, therefore, involves medical judgment", so the claim IS eligible for external review.

The example goes further and says the plan's final notice was inadequate for failing to describe the standard it applied. So a denial that gives you nothing to answer is itself a defect worth naming. Quote the example by number when you ask for external review; it is not an interpretation you are offering, it is the text of the rule.

The same logic applies whenever a plan assesses whether in-network providers can do what you need. The moment it judged capability, it made a medical judgment, whatever it called the letter.

Ask the plan, IN WRITING, to state whether external review is available for your denial and on what basis it decided that. Plans block this step by classifying a network or benefit-level denial as something other than medical necessity, and it happens on the phone rather than in a letter. The page on calling your insurer sets out how to ask.

Scope first, because this is the step most likely to bounce a reader with an exclusion denial. External review generally reaches determinations involving MEDICAL JUDGMENT, and rescissions. A denial resting on a categorical plan exclusion is frequently declined by the review organization on the ground that no medical judgment is involved.

File anyway, and know what to do with a refusal. Ask the plan in writing to state the basis on which your denial was classified as ineligible and to name the organization that decided it. An exclusion denial often contains a medical-necessity judgment inside it, and saying so specifically is the argument. The ineligibility letter is also documentary proof that the independent route was closed to you, which is worth having in front of a regulator.

Under 29 CFR 2590.715-2719(d)(2)(iv) the plan must provide coverage or payment IMMEDIATELY when the reviewer reverses it — authorizing the care or paying the benefit without delay. The state-process equivalent at (c)(2)(xi) requires benefits without delay too.

The decision binds the plan, and there is no further round for it.

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.