How to Request an External Review of an Insurance Denial

Your internal appeal was denied. You went through the insurance company's own process and they still said no. You might be feeling like it's over.

It's not.

External Independent Review: Complete Guide" class="auto-link">External review is one of the most powerful and underused tools in the insurance appeals process. It takes your case out of the hands of the insurer — entirely — and puts it before an independent third party who has no financial interest in the outcome.

External reviewers overturn insurer decisions roughly 40% of the time nationally, and at even higher rates for certain denial types. This is a real, consequential review — not a rubber stamp.

Here's everything you need to know to request one.

What Is External Review?

External review is a formal review of your insurance denial by an IROs) Explained" class="auto-link">Independent Review Organization (IRO) — a company that specializes in health claim reviews and has no financial relationship with your insurance company.

Under the Affordable Care Act and ERISA, most health plans are required to offer an external review process. The IRO is selected from a state or federal list of approved organizations. Once the IRO makes a decision, it is binding on the insurance company. They must comply with it.

This is different from your internal appeal, where the insurer's own employees review your case. In external review, the reviewers are completely independent.

Who Is Eligible for External Review?

ACA-compliant plans (individual market, small group, and many large group plans): External review is available after you exhaust your internal appeal rights, or if the insurer fails to meet internal appeal timelines.

ERISA employer-sponsored plans: Federal external review requirements apply. Most employer plans offer external review even if not technically required by state law.

Medicare: Medicare has its own equivalent — independent external review through a Qualified Independent Contractor (QIC) at Level 2, and further review levels above that.

Medicaid: Varies by state — some states offer independent external review, others use a fair hearing process.

Not eligible: Grandfathered plans, short-term plans, and certain self-funded employer plans may have limited or no external review rights. Check your plan documents.

When Can You Request External Review?

You can request external review after:

1. You have received a final denial from your internal appeal, OR
2. Your insurer has failed to respond to your internal appeal within the required timeframe (this counts as an exhaustion of internal remedies in many states)

Expedited external review is available when your situation involves urgent or emergency care — the external review must be completed within 72 hours.

Your Deadlines for Requesting External Review

Missing these deadlines can forfeit your right to external review:

• ACA plans: Request external review within 60 days of receiving your internal appeal denial
• ERISA employer plans: Request within 4 months (122 days) of internal appeal denial
• Medicare: Varies by level — request Level 2 review within 180 days of Level 1 denial for standard, or 72 hours for expedited

Act as soon as you receive your internal appeal denial. Don't wait.

Step-by-Step: How to Request External Review

Step 1: Confirm external review is available to you

Your internal appeal denial letter is legally required to include:

• Information about your right to external review
• Instructions on how to request it
• The applicable deadline

Review that letter carefully. If the information isn't there, call member services and ask for your external review rights in writing.

Step 2: Identify who processes the external review request

This depends on your plan type:

• Fully insured plans (plans sold by insurance companies in your state): External review is usually administered through your state's insurance department or through an IRO designated by your state. Contact your state insurance department for the correct process.

• Self-funded employer plans: These plans follow federal ERISA external review rules. Your plan documents will specify the process, or call HR/plan administrator.

• ACA Marketplace plans: Contact the Marketplace or your insurer for external review instructions. In some states, the process runs through the state insurance department; in others, through the insurer.

Step 3: Gather and submit your documentation package

Your external review request should include:

• A formal written request for external review
• A copy of the denial letter(s) — both your original denial and your internal appeal denial
• Your complete appeal documentation — medical records, letters of medical necessity, clinical guidelines, personal statement
• A clear, brief cover letter summarizing why the denial is wrong

The IRO will also request records from your insurer, but give them everything you have. More is more.

Step 4: The IRO Review Process

Once your request is filed:

• The IRO notifies your insurer and requests the complete claim file
• The IRO assigns a medical reviewer with appropriate clinical expertise for your condition
• The reviewer evaluates all submitted materials independently
• Standard review: decision within 30–45 days (varies by state and plan type)
• Expedited review: decision within 72 hours

You can submit additional information to the IRO during the review period if you have new evidence.

Step 5: Receive the Decision

The IRO issues a written decision explaining their finding. If they rule in your favor:

• The decision is binding on the insurer
• The insurer must comply — approving the treatment, authorizing the care, or reimbursing the claim
• You should receive written confirmation from your insurer of how they will implement the decision

If the IRO upholds the denial:

• You've exhausted the formal insurance appeals process
• Legal action, state regulatory complaints, and ombudsman assistance are still available

What External Reviewers Look For

External reviewers evaluate the clinical merits of the case independently. They're not rubber-stamping the insurer's decision — they're making their own independent medical determination.

They give significant weight to:

• Your treating physician's clinical opinion and documentation
• Published clinical guidelines from major medical societies
• Peer-reviewed medical literature
• The appropriateness of the insurer's applied criteria
• Clinical expertise matching your condition (they should have a reviewer with relevant specialty knowledge)

Cases that succeed at external review typically have strong physician documentation, solid clinical evidence, and clear arguments that the insurer's criteria were misapplied.

External Review Is Worth Pursuing

The data is clear: external review succeeds a significant percentage of the time. And for patients who've already exhausted internal appeals, it's often the last formal step before legal action.

Don't skip it. Don't miss the deadline. File as soon as your internal appeal is denied.

Fight Back With ClaimBack

ClaimBack helps you navigate the external review process — from preparing your documentation package to understanding the timeline and escalation options.

Start your appeal at https://claimback.app/appeal

Your case isn't over. Request external review.

Related Reading

• Internal vs. External Insurance Appeal: Which Should You File?
• How to Request an External Review of an Insurance Denial
• Common Reasons Insurance Claims Are Denied