Questions & answers · Health insurance
What is external review of a health insurance denial, and how long does it take?
Health insuranceAppealChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: 45 CFR 147.136 (eCFR (current as of 2026-11-02)) · § 147.136(d)(1)(i) View original ↗
In short
- External review means an outside group looks at your denial.
- Ask for it within four months.
- It decides in 45 days, or 72 hours if urgent.
What this means
External review means an independent review organization (IRO) looks at your denial. It is for denials that involve medical judgment. Examples are medical necessity, or whether a treatment is experimental [1]. You must ask within four months after you get the denial notice or the final internal denial. State processes must allow at least four months [2]. The IRO must decide in writing within 45 days after it gets your request. If your health needs a fast review, the limit is 72 hours [3]. If the IRO reverses the denial, the plan must cover or pay for the care right away [4].
Where this comes from (4)
[1] 45 CFR 147.136 (eCFR (current as of 2026-11-02)) · § 147.136(d)(1)(i) · checked 2026-11-05
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
[2] 45 CFR 147.136 (eCFR (current as of 2026-11-02)) · § 147.136(d)(2)(i); (c)(2)(vi) · 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.
[3] 45 CFR 147.136 (eCFR (current as of 2026-11-02)) · § 147.136(d)(2)(iii)(B)(6); (d)(3)(iv) · 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. … 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
[4] 45 CFR 147.136 (eCFR (current as of 2026-11-02)) · § 147.136(d)(2)(iv) · checked 2026-11-05
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 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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