During an external review, an independent third party reviews your insurer’s decision.[7] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

Under District of Columbia law, you are entitled to request an external in the following circumstances:

  • Your insurer denies your coverage after an internal appeal within the allotted timeframe;
  • The insurer waives the requirement that the internal appeals process be completed before proceeding to external review; or
  • The insurer does not comply with the deadlines and requirements of the internal appeals process.[8]

You can request an expedited external review if you have an urgent or emergency medical condition. If you believe you qualify for an expedited external review, you can apply for that at the same time that you apple for an expedited internal appeal.