How long do I have to request external review?

Federal consumer guidance gives a four-month window after receipt of the relevant adverse benefit determination or final internal denial. Use the exact deadline and destination in your notice because the applicable state, federal, or plan-contracted process controls.

How long does external review take?

Standard external review must be decided as soon as possible and no later than 45 days after receipt. An eligible expedited review must be decided as medical circumstances require and no later than 72 hours.

Is the external reviewer's decision binding?

HealthCare.gov states that the insurer must accept the external reviewer's decision. Under the HHS-administered federal process, the decision is binding on the claimant and plan or issuer, subject to other remedies that may exist under federal or state law.

What kinds of denials qualify for external review?

Federal categories include denials involving medical judgment, experimental or investigational determinations, rescissions, and determinations about compliance with No Surprises Act billing and cost-sharing protections. Pure eligibility or contractual disputes may use a different route.

External review: an independent look at the denial

UPDATED JULY 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.

Federal external-review benchmarks

Request deadline: within 4 months after receiving the relevant denial or final internal determination.
Standard decision: as soon as possible, no later than 45 days after the request is received.
Expedited decision: as medical urgency requires, no later than 72 hours.
Effect: the plan or insurer must accept the external reviewer's decision under the applicable process.

Current federal-process notice — July 2026

If you live in Alabama, Florida, Georgia, Texas, Wisconsin, or a U.S. territory other than Puerto Rico and your plan or issuer uses the HHS-Administered Federal External Review Process (FERP), HealthCare.gov says that process has been temporarily unavailable since July 1, 2026. HHS says it is working on a solution and will provide more information about deadline extensions for eligible people.

Check the live HealthCare.gov external-review notice and follow the instructions in your denial if your coverage uses another process. Confirm current instructions rather than assuming an automatic deadline extension.

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.
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

Free template — standard or expedited external review

[Your name] · Member ID: [ID] Claim / Authorization #: [number] · [Date] [External review organization or agency] [Address, fax, email, or portal from final denial] RE: REQUEST FOR [STANDARD / EXPEDITED] EXTERNAL REVIEW Final internal denial dated: [date] Service or treatment: [name] To the External Reviewer: I request independent external review of the enclosed final internal adverse benefit determination. ELIGIBLE ISSUE. The denial involves [medical necessity / appropriateness / level or setting of care / effectiveness / experimental or investigational treatment / rescission / No Surprises Act compliance]. The plan's stated reason is: "[quote the final denial]." WHY REVIEW IS REQUESTED. [Briefly identify the specific plan criterion or medical judgment in dispute. Refer to the enclosed treating-clinician letter and records; do not make unsupported medical claims.] [IF EXPEDITED] EXPEDITED REVIEW REQUEST. My treating clinician states that waiting for standard review would seriously jeopardize [life / health / ability to regain maximum function] because [brief factual explanation]. The signed clinician statement is enclosed. Please confirm receipt, eligibility, and the review deadline in writing. If anything required is missing, contact me promptly at [phone/email]. Enclosed: external-review form; initial and final denial notices; EOB; internal appeal; treating-clinician letter; relevant medical records; plan and policy excerpts; supporting evidence; representative authorization, if applicable; proof of timely filing. Sincerely, [Signature] · [Name] · [Phone] · [Email]

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.

Make the review file easy to follow

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Frequently asked questions

Can my doctor file for me?

Yes. HealthCare.gov says you may appoint a representative, including a doctor or another medical professional familiar with your condition. Complete any authorization form the applicable process requires.

Can I send more evidence than I used in the internal appeal?

The HHS-administered federal process permits claimants to submit additional information by the applicable deadline. A state or contracted process may have different submission instructions, so send evidence through the route identified in your notice and keep proof.

What if the external reviewer upholds the denial?

The external-review process ends with that determination, subject to any other rights or remedies available under the governing plan, state law, or federal law. A state Consumer Assistance Program, insurance regulator, EBSA benefits adviser, or qualified attorney can explain options for a specific case.

Where can I get free help identifying the right process?

HealthCare.gov links to state Consumer Assistance Programs and insurance departments. For private-sector job-based coverage, contact EBSA at 1-866-444-3272.