Your deadline
Four months from the date you RECEIVED the final internal denial. This one is a hard federal deadline and there is no appeal from missing it. The box is here because this is the page you are on when you act.
This is not everyone’s clock. Medicaid or CHIP, Medicare, TRICARE, VA health care and a church or government employer plan run on different rules. Do not assume the number above is yours.
Work out your own deadlineWhat 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.
If they tell you it is not eligible for external review
Expect this if your denial rests on a plan exclusion rather than on medical necessity. Independent review organizations frequently decline those, on the basis that no medical judgment is involved. It is the most common way this step fails and almost nobody warns you.
It is not necessarily the end. Ask the plan, in writing, to state the basis on which it classified your denial as ineligible and to identify the review organization that made that call. A denial framed as an exclusion often still contains a medical-necessity judgment inside it, and saying so specifically is the argument. Meanwhile the ineligibility letter is itself useful: it is documentary proof that the independent route was closed to you, which matters to a regulator and to a lawyer.
What winning actually gets you
This is the most motivating fact about external review. Under 29 CFR 2590.715-2719(d)(2)(iv), when the reviewer reverses the plan, the plan must provide coverage or payment IMMEDIATELY — authorizing the care or paying the benefit without delay. The state-process equivalent at (c)(2)(xi) says the same thing.
The decision binds the plan. It is not advisory, and the plan does not get another round.
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]
Both stay on your device. Neither one sends anything to this site.
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