During an external review, an independent third party reviews your insurer’s decision.^[14] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

You can request an appeal in the following situations:

• Your group health insurer denies your internal appeal;
• Your individual health plan insurer follows the internal appeals process and your appeal is denied;^[15] or
• Your situation is urgent, in which case you would request an expedited external review.^[16]

Your situation is considered urgent if one of the following applies:

• Waiting up to 45 days to receive your requested treatment would seriously jeopardize your life, health, or ability to regain maximum function; or
• You are currently receiving inpatient emergency services, have not been discharged from the facility yet, and your requested treatment relates to the emergency services.^[17]

If you qualify for an expedited external review, you can request it at the same time that you request the expedited internal review.^[18]