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The Federal External Review Process allows for an independent, outside review of adverse benefit decisions by health plans. Adverse benefit decisions mean the plan decided against your request to authorize care or they refuse to pay for services already performed.

Consumers or their authorized representatives (sometimes called “claimants”) have the right to ask for an internal appeal.  In an internal appeal, the plan looks at their adverse benefit determination again. If the plan still denies payment or service after the internal appeal, they will issue a "final internal adverse benefit determination." This means their final decision is that their original denial was right.

The law allows the consumer to ask for an external review of the plan's final decision. This is a review of the final internal adverse benefit determination by an independent third party.

In some cases, a consumer can ask for an external review without having an internal appeal first.  In those cases, the consumer can request an external review of the plan's original decision to deny a benefit or refuse payment.

The purpose of the external review is to find out if the health plan's decision was right. There is a standard external review and, for urgent cases, an expedited (faster than usual) external review.

The external review can be for adverse benefit determinations that involve:

  • Medical necessity

  • Appropriateness

  • Health care setting

  • Level of care

  • Effectiveness of a covered benefit

  • Whether a treatment is experimental or investigational

  • Any other matter that involves medical judgment

If your health insurance is retroactively cancelled, you may also request an external review. Retroactive cancellation is sometimes called rescission of coverage. It means that the plan cancelled your coverage back to an earlier date.

You may also ask for an external review if the plan denies your application for individual health insurance.

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