What’s an “external appeal?”
An external appeal or “external review” is a review of your insurance company’s decision. This process varies by state.
Who conducts the appeal?
The external appeal is handled by an independent third party agency, generally a government agency or an organization contracted by a government agency. The external appeal, similar to the insurance company appeal, is rather informal and not the courtroom drama that you may see on TV. Rather, the external appeal is handled almost exclusively by written documentation and when necessary, phone calls.
What types of external appeals are there?
Types of external appeals include a denial that involves medical judgment (“medical necessity”), a denial for experimental treatment and a cancellation of coverage.
How am I represented in this? Do I have to handle it on my own?
For an external appeal, you may appoint a representative or represent yourself. Your representative does NOT have to be an attorney.
Does this cost me anything?
Federal external reviews, for those states that chose them, are free; otherwise the cost of an external appeal is less than $25.
How long does an appeal take?
As a timeline, you have limited time from the insurance decision to file an external appeal. The insurance company decision notice will direct you on how to file an external appeal. Note there is also an option for an expedited appeal with a 72-hour decision in the case of an emergency.
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