During an external review, an independent third party reviews your insurer’s decision.[6] You can request an external appeal in the following circumstances:

  • You requested an internal appeal from your insurer, but your insurer did not provide you with a prompt hearing or a decision within 30 days (if you have not yet received the requested service or treatment) or 60 days (if you have received the service or treatment but are waiting for reimbursement);[7]
  • Your insurer denies your internal appeal;
  • Your situation is urgent (request an expedited external review);[8]
  • Your health insurer denied your claim because it deemed your requested treatment “experimental” and you meet all of the following criteria:
    1. You have a terminal condition with a substantial probability of death within two years or your ability to regain or maintain function would be impaired;
    2. You have already tried standard treatments, your health care provider certifies that the standard treatment is not medically indicated for your condition, or there is no standard treatment;
    3. Your health care provider recommends and certifies in writing that the proposed treatment is more beneficial to you than the standard treatment;
    4. Your health care provider has certified in writing that scientific studies, using accepted protocols and published in peer reviewed literature, demonstrate that the proposed treatment is likely to be beneficial to you than the standard treatment; and
    5. Your insurance policy says that the treatment should be covered, and the only reason it was not covered was because your insurer determined that it was experiment.[9]

You should submit a written request for a standard or an expedited external review to the Georgia Department of Insurance.[10] Your insurer should have provided you with instructions on how to submit the request and what information, documentation, and procedures are required for external review of your case.[11] If you cannot find the instructions, contact your insurer.