How do I request an external review?

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You should submit your request for external review to the New Hampshire Insurance Department (“Department”) within 180 days from when your insurer sent you the most recent decision.^[5] Information. You can find a copy of the external review request form here. You should include the following information with your request:

The name, address, email address, and telephone number of the applicant;
The patient’s name and date of birth (if different from the applicant);
The name and relationship to patient of the insured;
The name, address, and telephone number of the insurance company;
The name of the claim representative handling your appeal;
Member identification number and claim or reference number;
The name and telephone number of the employer;
The name, address, and telephone number of your primary care provider;
The name, address, telephone number, and specialty of your treating health care provider; and
Description of the complaint; and
The health care provider certification form in the external review application (this form is only required for expedited external review requests.)^[6]

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

A signed medical records release form (included in the external review form packet);
A copy of your insurance card or other evidence showing coverage;
A copy of the final determination letter from your health insurer;
A copy of medical records, statements from your health care provider, or other information you’d like the external review organization to consider;
A copy of your insurance policy; and
Any new information or documentation not included with your request for an internal appeal.^[7]

Submitting a standard external review. If you are requesting a standard external review, you should mail the completed form and supporting documents to the following address: New Hampshire Insurance Department Attn. External Review Unit 21 South Fruit Street, Suite 14 Concord, NH 03301^[8] Submitting an expedited review. If you are requesting an expedited external review, you can fax your request to (603) 271-1406 or send it by overnight mail to the address above.^[9]