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 Texas law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal because it determines that the treatment is experimental, investigational, medically unnecessary, or inappropriate. You cannot ask for an external review if your policy does not cover the denied services.[4]

You can also request an expedited external review if you or your health care provider believes that your condition is life threatening or if your plan denies coverage for a prescription drug or intravenous infusion for which you are currently receiving benefits.[5] You should call your insurer and find out if you can skip the internal review process if you qualify for an expedited external review.