Internal appeal vs external review: what is the difference
Internal appeals go to the insurer. External review goes to an independent third party. Here is when each applies and the order they happen in.
Internal appeal first
Most plans give you 180 days from the date of denial to file an internal appeal.
Many plans have two levels of internal appeal before external review becomes available.
External review
After the final internal denial, you have 120 days to request external review by an Independent Review Organization (IRO).
External review is binding on the insurer. If the IRO sides with you, the insurer must pay.
Federal external review applies to most ERISA and marketplace plans; state external review applies to fully-insured state plans.
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Is external review free?+
Yes for the consumer. Federal and state external review programs do not charge the member.
Can I go straight to external review?+
Only in narrow cases: when the insurer waives internal review, fails to follow procedure, or for urgent care.
More guides
- How to write a health insurance appeal letter
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills
- Health insurance appeal deadlines you need to know