During an external review, an independent third party reviews your insurer’s decision.[6] You can request an external review of the insurer’s decision in the following circumstances:

  • You requested an internal appeal but your insurer did not give you a decision within 60 days;[7] or
  • Your insurer denied you coverage after you requested an internal appeal.[8]

You can skip the internal appeals process and request an expedited external review if you have an emergency medical condition.[9] Your condition is considered an “emergency medical condition” if:

  • Your condition is sudden, unexpected, and requires immediate medical attention;
  • If waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function;
  • Your health insurer has determined that the requested treatment is experimental or investigational; or
  • Your health care provider certifies in writing that the requested treatment would be significantly less effective if not initiated promptly.[10]