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Expedited External Review

In some cases, a person may ask for an expedited (faster than usual) external review. An expedited review may be requested when:

 

1.   The person has asked for an expedited internal appeal and wants an expedited external review at the same time, and the timeframe for an expedited internal appeal (72 hours) would place the person’s life, health or ability to regain maximum function in danger.

 

OR

 

2.   The person has completed an internal appeal with the plan and the decision was not in his or her favor, and:

 

a.  The timeframe to do a standard external review (45 days) would place the person’s life, health or ability to regain maximum function in danger, or

 

b.  The decision is about admission, care availability, continued stay, or emergency health care services where the person has not been discharged from the facility.

 

When requesting an expedited external review, a person must provide the following information:

  • Name and Address
  • Phone
  • Email address
  • Whether the request is urgent
  • Patient’s signature if person filing the appeal is not the patient
  • A brief description of the reason you disagree with your plan’s denial decision

You may use an HHS Federal External Review Request Form to provide this and other additional information.

An expedited external review happens faster if a person asks for it by calling our toll-free telephone number: 1-888-866-6205.

The 72-hour timeframe for an expedited request begins when the phone call ends.



Instructions for Sending Your Expedited External Review Request:

A person may also ask for an expedited external review by mail or fax. The 72-hour timeframe for expedited requests sent by mail or fax begins when the request is received.


By Mail:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534


By Fax:
1-888-866-6190



What Happens Next?

 

 

The MAXIMUS Federal Services examiner will contact the health insurance plan immediately upon receipt of the request for external review. The plan must give the examiner all documents and information used to make the internal adverse benefit decision as expeditiously as possible.   


The MAXIMUS examiner will give the claimant and the health plan the external review decision as quickly as medical circumstances require, but no later than within 72 hours of receiving the request. 


The MAXIMUS examiner can give the external review decision orally, but it must be followed up by a written version of the decision within 48 hours of the oral notification.

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