Deadlines. You must submit a written request for a standard external review to your health insurer within 60 days from the date of the insurer’s final decision and within 15 days if you are requesting an expedited external review.[7] Your health insurer should have sent you information on how to submit the external review request when it denied your internal appeal.[8]

Supporting documents. You should include the following documents with your request:

  • A signed medical record release form (appendix B of the Patient’s Guide to External Review); and
  • Any new information and documentation that you did not include with your previous request for an internal appeal.[9]

If your insurer denied your claim because the requested treatment or service was considered experimental or investigational, you must include a letter or certificate from your physician.[10] The requirements for physician’s certification are included on page 7 of the Patient’s Guide to External Review.

Independent Review Organization’s Duties. Once your health insurer receives your external review request, it will assign your request to an independent review organization (“IRO”), send the IRO copies of all documents and information it relied upon in denying your request, and send you notice of these actions.[11] The IRO will contact you within five days of receipt of the external review request if it needs additional documents or information. You will have seven business days to provide them with the requested information.[12]