My health plan upheld its denial after my internal appeal. What is external review?

Health insuranceComplaint / outside reviewChecked Nov 5, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: eCFR · 45 CFR 147.136(d)(2)(i) (row aca-ext-file) View original ↗

In short

External review means an outside group looks at your case.
Ask for it within four months of the final denial.
It must decide in 45 days, or 72 hours if urgent.

What this means

You can ask for external review within four months after receiving the denial or the final internal denial [1].

Federal external review covers denials that involve medical judgment, such as medical necessity, appropriateness, health care setting, level of care, effectiveness of a covered benefit, or a finding that a treatment is experimental or investigational [2].

The independent review organization must give written notice of its decision within 45 days after it receives the request. In expedited cases, it has no more than 72 hours [3].

HealthCare.gov says the HHS-administered process has no charge. Under a contracted IRO or a state process, any charge can't be more than $25 per review. For the HHS process, call toll free 1-888-866-6205 to request a form, then fax the request to 1-888-866-6190 [4].

Your next step

+ deadline: request external review within four months of the final denial notice [1].

Where this comes from (4)

[1] eCFR · 45 CFR 147.136(d)(2)(i) (row aca-ext-file) · checked 2026-11-05
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.
[2] eCFR · 45 CFR 147.136(d)(1)(i) (row aca-ext-scope) · checked 2026-11-05
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
[3] eCFR · 45 CFR 147.136(d)(2)(iii)(B)(6); (d)(3)(iv) (row aca-ext-decide) · checked 2026-11-05
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. … in no event more than 72 hours after the IRO receives the request
[4] HealthCare.gov · External Review · How much does an external review cost? (row aca-ext-cost) · checked 2026-11-05
If your health insurance company is using the HHS-Administered Federal External Review Process, there's no charge. … the charge can't be more than $25 per external review. … Call toll free: 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.

How we found this

We matched your question to 4 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.

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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