External review: an independent look at the denial

UPDATED JULY 12, 2026 · U.S. COMMERCIAL PLANS · NOT LEGAL OR MEDICAL ADVICE

External review moves an eligible dispute outside the health plan to an independent review organization. The route may be state-run, HHS-administered, or arranged by the plan. Your final internal denial should identify the correct destination, and the filing window is short enough that the first job is to find and preserve the deadline.

Step 1 — Confirm that the dispute is eligible

Federal external-review categories include:

• A denial involving medical judgment, such as medical necessity, appropriateness, care setting, level of care, or effectiveness of a covered benefit.
• A determination that treatment is experimental or investigational.
• A rescission, meaning certain retroactive cancellations of coverage.
• A determination about whether the plan followed No Surprises Act billing and cost-sharing protections.

Not every coverage dispute uses this process. A pure eligibility, worker-classification, or contractual benefit-exclusion issue may have a different route. The final internal denial should state whether external review is available and how to request it.

Step 2 — Find the correct reviewer

The reviewer depends on the plan and state:

• Individual, Marketplace, and fully insured employer coverage may use an applicable state external-review process, an HHS-administered federal process, or an insurer-contracted independent review organization. California residents with a DMHC-regulated plan, for instance, generally use the state's free Independent Medical Review (IMR) program instead of the federal process.
• Self-funded private employer plans generally identify their federal or plan-contracted external-review route in the final denial and Summary Plan Description.
• Medicare, Medicaid, TRICARE, VA, and IHS coverage use separate review systems; this guide does not describe those programs.

Use the address, portal, form, and deadline printed in the final denial. If they are missing or unclear, check the CMS state and federal external-review list. For job-based coverage, the U.S. Department of Labor's Employee Benefits Security Administration can be reached at 1-866-444-3272.

Step 3 — Decide whether internal review must finish first

Most people request external review after the plan issues a final internal denial. In an urgent medical situation, federal guidance allows an expedited internal appeal and expedited external-review request at the same time when the standard timeline would seriously jeopardize life, health, or the ability to regain maximum function. A plan's material failure to follow required internal procedures can also affect exhaustion rules. Because those exceptions are fact- and plan-specific, use the denial instructions and seek regulator or qualified professional help if the route is disputed.

Step 4 — Submit a complete request before the deadline

• The external-review request form or a written request that contains every item the notice requires.
• The initial denial, final internal denial, EOB, and a copy of the internal appeal.
• The plan language and clinical policy at issue.
• A treating-clinician letter that addresses the denial reason and urgency, if relevant.
• Relevant records, test results, guidelines, and peer-reviewed evidence selected with the clinician.
• An authorization form if a clinician or other representative is filing for you.
• Proof of submission: portal confirmation, fax record, or tracked-mail receipt.

Under the HHS-administered federal process, the plan or issuer sends its decision file to the reviewer, and the claimant may submit additional information by the applicable deadline. State and contracted-review processes may use different forms and transmission rules.

External review request template

What happens after filing

The reviewer first checks whether the request is eligible and timely, then reviews the plan record and information submitted by you or your representative. The decision either upholds or reverses the denial. HealthCare.gov states that the insurer must accept the external reviewer's decision. Other remedies may still exist under state or federal law, but they are outside this general-information guide.

The HHS-administered federal process is free to consumers. HealthCare.gov says a state or insurer-contracted process may charge a fee, but no more than $25 per external review. Confirm the applicable process before sending payment.

Frequently asked questions

Authoritative sources

• HealthCare.gov — External review, deadlines, costs, and the current July 2026 FERP notice
• CMS — HHS-Administered Federal External Review Process
• CMS — State and federal external-review processes
• U.S. Department of Labor — Filing a claim for your health benefits
• HealthCare.gov — Find consumer help for your coverage