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.

 You are entitled to an external review in the following circumstances:

  • Your insurer denies your coverage after an internal appeal because your insurer determined your claim was not medically necessary, medically inappropriate, or is considered cosmetic, experimental or investigational; or
  • Your medical situation is urgent and waiting would jeopardize your life or ability to function.

Please note that if your situation is urgent, you do not need to wait for a decision from your insurer on the internal grievance. You can request an expedited external review while you request an expedited internal grievance from your insurer.