During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say whether to approve a treatment or pay a claim.

In South Carolina, you can request a standard external review if you meet all of the following qualifications:

  • Your insurer denied, reduced, or terminated your requested service because it (1) did not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or (2) it was experiment or investigational and involves a life-threatening or seriously disabling condition; and
  • Your insurer is required to pay at least $500 for the requested treatment or service; and
  • You have completed the internal appeals process or meet an exception for this requirement.[4]

You can request an external review before completing the internal appeals process if you have not yet received your requested service and one of the following applies:

  • Your treating physician has certified in writing that you have a serious medical condition (if this is the case, you also qualify for an expedited external review);
  • Your requested service is experimental or investigational and your treating physician has provided you with required certifications;
  • Your insurer has not provided you with a written decision within the timeframe required for the internal appeals process even though you provided your insurer with all of the requested information; or
  • Your insurer waived the internal appeals process.[5]

In certain circumstances, you can request an expedited external review, which means you do not need to finish the internal appeals process and the independent review organization must provide you with a decision within three business days. You should consult with your insurer to determine whether you can skip the internal review process altogether. You can request an expedited external review in the following circumstances:

  • Your treating physician has certified in writing that you have a serious medical condition; or
  • You received emergency medical care, have not been discharged from a facility, and may be held financially responsible for the emergency medical care.[6]