During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Oregon law, you are entitled to request an external review in the following circumstances:

  • If your insurer denies your coverage after an internal appeal because it determined that the requested treatment or service were medically unnecessary, experimental/investigational;
  • You are trying to avoid a disruption in your care; or
  • You are disputing the appropriate setting for treatment or the appropriate level of care; or
  • Your health insurer rescinded or ended your coverage.[4]

You can request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or health.[5] You should request the expedited external review at the same time that you request the internal appeal.