External Review After an Insurance Appeal

1. Start with the final denial notice

Read the whole notice confirming the internal appeal decision. Check the exact reason for the denial, any plan provision or clinical rationale it cites, whether the plan says another internal level remains, and the date the decision was issued. Keep the notice and the EOB together; they may identify who handles external review and how to contact them.

If the notice does not clearly say whether you have reached the final internal decision, ask the plan administrator or insurer. If waiting could seriously affect your health, ask right away whether an expedited route is available and what to do.

Official sources: HealthCare.gov: External review; U.S. Department of Labor (DOL): Filing a claim for your health benefits; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions

2. Identify the process that applies to your plan

Follow the external-review instructions in the final denial notice and EOB. For many private plans, the review may run through a state process or a federal process; job-based plans can also differ depending on whether they are insured or self-funded. If the notice is unclear, ask the plan who accepts the request and whether an additional internal appeal is required.

Review the coverage document that fits your plan, such as an Evidence of Coverage, certificate, policy, Summary of Benefits and Coverage, or employer plan Summary Plan Description. These materials may explain the appeal route, eligibility rules, and where forms must go. Use your state insurance department’s official site for state-specific information; a federal overview is not a substitute for your plan’s instructions. Medicare and Medicaid use program-specific appeal routes.

When you call, confirm the applicable external-review organization or office, the exact filing deadline and the date it is measured from, which form to use, accepted submission methods, any representative authorization, and how to request an expedited review if needed.

Official sources: HealthCare.gov: External review; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions; U.S. Department of Labor (DOL): Filing a claim for your health benefits; National Association of Insurance Commissioners (NAIC): Find an insurance department

3. Confirm the deadline before you prepare the request

HealthCare.gov’s external-review overview describes a written request within four months after you receive the denial notice or final determination. Treat that as general federal consumer guidance, not a personalized deadline: verify the date and instructions in your own notice and plan materials, and contact the plan or state insurance department promptly if they are missing or inconsistent. Do not assume an internal-appeal deadline is also the external-review deadline.

Write down when you received the final decision and the last day to submit. If you are unsure how the date is calculated, ask the organization handling review and keep a note of the answer.

Official sources: HealthCare.gov: External review; National Association of Insurance Commissioners (NAIC): How to appeal denied claims

4. Gather the information and records

Use this checklist to organize your materials. It is not a universal list of required documents; the form and instructions for your plan and state control what to submit. Send copies unless the instructions specifically require an original.

Your name and contact information, the patient’s name if different, member ID, claim number, and any representative authorization the plan requires.
The date of the service or claim, the final internal decision date, when you received the notice, and the external-review deadline stated in the instructions.
Your plan or policy name and number, group number if applicable, and the relevant plan booklet, Evidence of Coverage, Summary Plan Description, or other coverage materials.
The final denial notice, Explanation of Benefits (EOB), earlier denial notices, and each internal appeal request and decision.
Copies of the records and evidence already sent, plus any relevant claim records, bills, clinical notes, test or imaging results, or provider explanation you may want considered.
The required external-review request form, the correct review organization or office, its contact details, and the accepted submission method and address.
A dated log of calls or messages, confirmation numbers, copies of what you submit, and proof of delivery or portal receipt.

Official sources: HealthCare.gov: Internal appeals; Centers for Medicare & Medicaid Services (CMS): Appealing health plan decisions; U.S. Department of Labor (DOL): Filing a claim for your health benefits; National Association of Insurance Commissioners (NAIC): How to appeal denied claims

5. Keep a record after you submit

Save a complete copy of the request and attachments, along with portal confirmations, mailing or fax receipts, and call notes. Check the process instructions for how the reviewer handles additional information and how the written decision will be sent. If you cannot identify the correct review contact or need help understanding your plan’s process, contact the plan administrator or your state insurance department.

Official sources: HealthCare.gov: External review; National Association of Insurance Commissioners (NAIC): How to appeal denied claims; National Association of Insurance Commissioners (NAIC): Find an insurance department

Official sources

For general steps before the final internal decision, return to the health-insurance appeal guide. For free assistance resources, see the appeal-support resource directory.