APPEALING A HEALTH PLAN DECISION

External Review

There are 2 steps in the external review process:

You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim has been denied.
External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.

Types of denials that can go to external review

Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
Any denial that involves a determination that a treatment is experimental or investigational
Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage