Your Rights in an External Review

Insurance denials are almost always upsetting and frustrating. But don’t forget that you have options and you don’t have to accept the denial as fact. If you receive a final denial from your insurance carrier, you may have the option to request an external review. An external review is when an independent third party reviews your health plan’s decision, and will either uphold the insurance company’s decision or decide in favor of the consumer by overturning all or part of the health plan’s decision.

As of 2012, health insurance companies in all states are required to participate in an external review process that meets minimum consumer protection standards as outlined in the Affordable Care Act. Requests for external review can only be made for denials related to covered services and cannot be considered for services identified under your plan’s exclusions or non-covered elements. You want to read your plan language and the denial letter closely regarding the process and timelines for an external review when considering going this route.

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