What to do
Confirm the internal process is finished
The letter should say final adverse determination or equivalent, and should include external review instructions.
Note the separate deadline
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.
Assemble the whole file
All denial letters, your appeal letters, clinician letters, clinical records, the plan's criteria, and your correspondence log.
Send to the address on the final denial
Some states route through the insurance department; some plans route directly to a review organization. Use what your letter says.
The request
[Your name] · [Member ID] · [Claim number] · [Today's date]
Re: Request for external review — final adverse determination dated [date]
I am requesting an external review of the final adverse benefit determination dated [date], denying coverage for [procedure or service] for the stated reason [quote it].
I have exhausted the plan's internal appeal process. [If applicable: the plan failed to meet its own deadlines, and I am also asserting deemed exhaustion.]
I am requesting a standard review. [Or: I am requesting an expedited review because delay would seriously jeopardize my health or my ability to regain maximum function, specifically (reason).]
Enclosed is the complete record: [list every enclosure].
Please confirm receipt and provide the name of the independent review organization assigned.
[Signature] · [Phone] · [Address]
Common questions
- Does it cost anything?
- Generally nothing or a nominal fee. Your final denial letter and your state insurance department can confirm.
- Can I add new evidence?
- Usually yes. Send the strongest complete record you have; the reviewer decides on what is in front of them.
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