If your insurer still denies you coverage after you requested an internal appeal or if your situation is urgent, you can request an external review of the insurer’s decision.[5] During an external review, an independent third party reviews your insurer’s decision.[6]

If you reside in Alaska, you should submit your request for an external review to your health insurer.[7] Your health insurer will submit your request to a qualified external review agency for consideration.[8] You will have an opportunity to send any documentation that your insurance company does not already have, including, but not limited to, additional medical records, the opinion of your treating physician, and any peer-reviewed studies applicable to your situation.[9] The external appeal agency will consider the following in making a decision in your case:

  • Guidelines or standards used by the health insurer in making its original decision to deny services;
  • Any personal health and medical information related to the condition for which treatment or medication has been denied to you;
  • Your physician or health care provider’s opinion; and
  • Your health insurance policy.[10]

The external appeal agency may also consider the following in making its decision:

  • Medical studies related to your condition;
  • The results of professional consensus conferences;
  • Practice and treatment guidelines;
  • Government-issued coverage and treatment policies;
  • Generally accepted principles of medical practice;
  • Expert opinions;
  • Peer reviews conducted by your health insurer; and
  • The community standard of care.[11]

You must file your written request for an external review within 60 days from the date that your insurer sent you the final decision.