During an external review, an independent third party reviews your insurer’s decision.[9] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New Jersey law, you are entitled to request an external review if:

  • Your insurer denies your internal appeal because it determined that the requested treatment or services were medically unnecessary, experimental, or investigational;
  • Your insurer has not complied with the deadlines for deciding your internal appeal;
  • Your insurer has waived the internal appeals process; or
  • Your situation is urgent and you requested an expedited internal appeal and an expedited external review at the same time.[10]

You can request an expedited external review if:

  • You seek urgent or emergency care, an admission, availability of care, or continuation of a stay;
  • You have received emergency services and have not yet been discharged; or
  • Waiting 10 to 20 days could seriously jeopardize your life, health, or ability to regain function.[11]