Can I get an outside review of my employer health plan's denial?

Health insuranceComplaint / outside reviewChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: govinfo · 45 CFR 147.136 · § 147.136(a)(1) View original ↗

In short

Many job-based plans must offer an outside review.
Ask within four months of the final denial.
If the outside reviewer sides with you, the plan must pay.

What this means

Group health plans that are not "grandfathered" must have internal appeals and external review [1]. You can ask for an external review. File the request within four months after you receive the denial or the final internal denial [2]. A denial that involves medical judgment can go to external review. Examples are medical necessity, the care setting, or a treatment called experimental [3].

The independent reviewer must give a written decision within 45 days after it gets the request. A fast review, when your health condition needs it, takes no more than 72 hours [4]. If the reviewer reverses the denial, the plan must pay or cover the care right away [5].

Your next step

Find the external review instructions in your final denial letter. File the request within 4 months after you receive it.

Deadline: 4 months.

Check it yourself

Which office handles your review: "Don't know yet" from these sources. Whether your plan is grandfathered: "Don't know yet" - the plan papers say. Denials that are only about whether you are eligible for the plan are not described in these sources.

Where this comes from (5)

[1] govinfo · 45 CFR 147.136 · § 147.136(a)(1) · checked 2026-11-06
This section sets forth requirements with respect to internal claims and appeals and external review processes for group health plans and health insurance issuers. … The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans, as defined under § 147.140.
[2] govinfo · 29 CFR 2590.715-2719 · § 2590.715-2719(d)(2)(i); (c)(2)(vi) · checked 2026-11-06
A group health plan or health insurance issuer must allow a claimant to file a request for an external review with the plan or issuer if the request is filed within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination.
[3] govinfo · 29 CFR 2590.715-2719 · § 2590.715-2719(d)(1)(i) · checked 2026-11-06
An adverse benefit determination (including a final internal adverse benefit determination) by a plan or issuer that involves medical judgment (including, but not limited to, those based on the plan's or issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; its determination that a treatment is experimental or investigational
[4] govinfo · 29 CFR 2590.715-2719 · § 2590.715-2719(d)(2)(iii)(B)(6); (d)(3)(iv) · checked 2026-11-06
The assigned IRO must provide written notice of the final external review decision within 45 days after the IRO receives the request for the external review. … as expeditiously as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request
[5] govinfo · 29 CFR 2590.715-2719 · § 2590.715-2719(d)(2)(iv) · checked 2026-11-06
Upon receipt of a notice of a final external review decision reversing the adverse benefit determination or final adverse benefit determination, the plan or issuer immediately must provide coverage or payment

How we found this

We matched your question to 5 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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