Independent medical review: how external review works in your state
After the final internal denial you have a federal or state right to independent medical review. Here is how the two tracks differ and how to file in your state.
Federal vs state external review
Federal external review under 45 CFR 147.136 covers most ERISA plans and qualified health plans not subject to a comparable state process. It is administered through HHS-contracted Independent Review Organizations (IROs).
State external review covers fully-insured plans regulated by the state insurance department. CMS keeps a list of which states meet the federal minimum standards.
Source: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.136 and https://www.cms.gov/cciio/resources/files/external_appeals.
When you can request it
After the final internal denial, you generally have 4 months (about 120 days) to request external review.
Expedited external review is available concurrently with internal appeal when delay would seriously jeopardize life, health, or ability to regain function — decision within 72 hours.
Eligible decisions include medical necessity, appropriateness of care, level of care, effectiveness of a covered benefit, and rescission decisions.
What the IRO decides
The IRO reviews the case de novo with a board-certified specialist in the relevant field. The plan must comply with the IRO decision; it is binding.
Strong submissions include: the full denial letter, the plan's clinical policy bulletin, all medical records cited, and a letter of medical necessity that maps to the policy criteria.
How to file in your state
If your plan is fully insured, request the form from your state Department of Insurance — most states publish it online.
If your plan is self-funded ERISA, follow the federal process named in your final internal denial letter (most plans use HHS-OPM contractor MAXIMUS).
Either way, the request is free for the consumer.
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Is the IRO decision really binding?+
Yes. Under 45 CFR 147.136 the plan must provide coverage if the IRO reverses the denial. Plans that refuse face federal enforcement.
Can I file external review without finishing internal appeal?+
Only in narrow cases: urgent care, the plan waives internal review, or the plan failed to follow the claims procedure (deemed exhaustion).
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills