If your insurer denies your coverage after the grievance process, you are entitled by law to request an external review from an independent third party, which means your insurer no longer has the final say over whether to approve a treatment or pay a claim.

You may request an external review if your insurer denies your claim during the grievance process for one of the following reasons:

  • The treatment is deemed not medically necessary;
  • The treatment is experimental;
  • The treatment is not as effective as other treatments; or
  • You require a different or lesser level of care.[13]

You can request an expedited external review if your medical situation is urgent and waiting the 45 days it would take to complete a standard external review would jeopardize your life or ability to function.[14]