Internal appeal vs. external review

Internal appeal

An internal appeal is your formal request that your insurer reconsider its denial. The same insurer that issued the denial also decides the appeal — but under federal rules, the appeal must be decided by people who were not involved in the original denial decision.

• Who decides: the insurer, using personnel not involved in the original decision.
• Deadline to file: usually 180 days from receiving the denial notice.
• Insurer must decide: 30 days for pre-service claims, 60 days for post-service claims, 72 hours for expedited appeals (urgent care).
• Cost: free.
• Outcome: upheld (denial stands), overturned (insurer pays), or partial overturn.

External review

If your internal appeal is upheld, you generally have the right to external review by an Independent Review Organization (IRO). The IRO is certified by your state and is independent of the insurer. Its decision is binding.

• Who decides: a certified IRO, with no financial relationship to your insurer.
• Deadline to request: typically 4 months after the final internal denial (varies by state).
• IRO must decide: 60 days for standard, 72 hours for expedited.
• Cost: free for consumers in most states; the insurer pays the IRO fee.
• Outcome: binding. If IRO overturns, the insurer must cover the service.

When external review applies

External review is available for denials based on:

• Medical necessity
• Appropriateness
• Health care setting
• Level of care
• Effectiveness of a covered benefit
• Determinations that a treatment is experimental or investigational
• Rescission of coverage

External review is generally not available for disputes that are purely about plan benefits — for example, a service that’s clearly excluded under the plan’s written terms.

State vs federal external review

Most states run their own external-review programs. A few (including Florida) defer to a federal HHS-administered process for most commercial plans. Self-funded employer plans usually use the federal process. Your denial letter and your state insurance department’s website will tell you which applies.

Practical tip — request expedited review when it’s warranted

If waiting for the standard timeline could jeopardize your health (for example, you have a scheduled surgery in 10 days, or you’ve been discharged from a hospital and need medication that’s being denied), you can request expedited internal appeal AND expedited external review simultaneously. Both must be decided within 72 hours. Few consumers know to do this.

InsureDefense supports both layers

Our standard tiers prepare your internal appeal. After your internal appeal is denied, our External Review Pack ($199) prepares the state-specific external review request, including the appropriate IRO submission form, your concise statement of the case, and the document checklist.

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