A person may submit a standard external review request via mail, fax, or submit an online request for an external review within four months after the date the consumer received the final internal adverse benefit determination notice.
To request an external review, a person must provide the following information:
- 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.
Also, a person may submit additional information for consideration of their external review request. For example, a person may provide:
- Documents to support the claim, such as physicians’ letters, reports, bills, medical records, and explanation of benefits (EOB) forms;
- Letters sent to your health insurance plan about the denied claim; and
- Letters received from the health insurance plan.
Instructions for Sending Your External Review Request:
You may mail a request for external review to the address listed on your final adverse benefit determination (denial) letter from your health insurance issuer, or you may mail your external review request directly to MAXIMUS:
By Postal Mail:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
By Fax: 1-888-866-6190
Online: www.externalappeal.com (forthcoming)
What Happens Next?
The MAXIMUS Federal Services examiner will contact the health insurance plan once we receive the request for external review. Within five business days, the plan must give the examiner all documents and information used to make the final internal adverse benefit determination.
The MAXIMUS examiner must give the claimant written notice of the final external review decision as soon as possible, but no later than 45 days after the examiner receives the request for an external review.