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]