During an external review, an independent third party reviews your insurer’s decision.[8] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal and did not receive a response within 30 days (if you did not receive the requested treatment or service) or 60 days (if the insurer denied payment for a treatment or service you did receive);[9]
  • You requested an expedited internal appeal and did not receive a response within 48 hours;
  • You received a denial letter after requesting an internal appeal or expedited internal appeal; or
  • Your insurer still denies you coverage after you requested an internal appeal.

To obtain an external review or expedited external review, you should complete the following steps:

Obtain documents. Collect the following documents for your external review request:

  • The external review request form packet (click here). You should use this form for both standard and expedited external reviews;
  • Release of medical records form, which is included in the external review request form packet;
  • Copy of your insurance card;
  • Copies of all determination letters and any other information that your insurer sent to you;
  • Medical records related to the condition for which you are seeking treatment;
  • Any peer review literature or clinical studies related to your requested treatment; and
  • Any additional information from your health care provider that you want the independent review organization to consider.[10]

Prepare your request. Complete the external review request form and medical release form. Be sure to include the following information:

  • The name, address, telephone number, and email address of the person filing the request (“applicant”);
  • Applicant’s relationship to the patient;
  • The name, address, telephone number, and email address of the patient, if different than applicant;
  • The name of the insurance company and name of the insured person;
  • The primary insured person’s identification number and patient identification number;
  • Whether the health plan is an individual plan, group plan through employer (and include employer’s name), or a group plan through a plan sponsor (and include the sponsor’s name);
  • The name, address, telephone number, and email address of the health care provider and name of the contact person at the provider’s office;
  • The reason for the appeal; and
  • A description of the treatment, service, drug, or procedure being denied, the date of service, and the date of denial.[11]

Submit your request. Submit your request for an external review or expedited external review and supplemental documentation within four months from the date that your insurer sent you the last determination letter. You can also fax your materials to (217) 557-8945 or email them to [email protected]. You can also mail your request to:

Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Request
320 W. Washington Street
Springfield, IL 62767[12]