If your insurer still denies you coverage after you requested a first and, if applicable, second level review, you can request an external review of the insurer’s decision.[7] If your situation is urgent, you can request an expedited external review. Your insurance company must provide you with information about requesting an expedited external review.[8] During an external review, an independent third party reviews your insurer’s decision.[9]

To request an external review, you should take the following steps:

  • Request documents from your insurer. Contact your insurer and request an external review form and a consent form that authorizes your insurer to release your records to an external review entity.[10]
  • Complete and submit forms. Complete and submit to your insurer the external review form, the consent form, and new information and documentation within four months of receiving the first level review decision or, if applicable, within 60 days of receiving the second level review decision.[11]

Once you submit your request for an external review to your insurer, the insurer will then forward the request to the Division of Insurance, which will assign the review to an external review entity.[12] The external review entity will review your medical records, your health care provider’s recommendation, consulting reports, any medical necessity criteria, and any medical or scientific evidence that is relevant to your case.[13]