State external review rights allow you to appeal an insurance denial to an independent expert. According to the Centers for Medicare & Medicaid Services (CMS), the independent reviewer's decision is legally binding on the plan. Under federal law and CMS guidance, all 50 states provide external review access either through their own state-run processes or through the federal MAXIMUS/FERP program run by HHS.
Unlike an internal appeal—where your insurance company reviews its own decision—an external review removes the insurer's authority entirely. An independent clinical expert with no stake in the outcome makes the final call, and your insurance company must follow it. If your claim has been denied and an internal appeal hasn't worked, external review can overturn the denial and secure coverage you've been refused.
Table of Contents
- External Review vs. Internal Appeal
- What External Review Can Cover
- How to Request External Review
- Finding Your State's External Review Process
- Timeline and Decision
- Frequently Asked Questions
External Review vs. Internal Appeal
When you file an internal appeal, your insurance company reviews its own decision—typically within 30 to 60 days—but retains the power to uphold or overturn its denial based on its own judgment. The insurer decides whether to reverse course or maintain the denial.
An external review removes that discretion entirely. The review is conducted by an independent clinical expert with no financial or personal stake in whether your claim is paid. Once this independent reviewer makes their decision, your insurance company has no choice but to follow it. This binding authority is what makes external review fundamentally more powerful than an internal appeal.
What External Review Can Cover
According to CMS, the independent examiner can review denials based on medical necessity, appropriateness of treatment, health care setting, level of care, treatment effectiveness, and whether a treatment is experimental. The scope expanded significantly in 2022 to include surprise billing disputes—unexpected out-of-network charges you receive even when the facility itself was in-network. So whether your denial stems from a disagreement about medical need, the type of care setting, or from a surprise bill, external review is available to challenge it.
How to Request External Review
File your external review request in writing to the contact provided in your insurance company's denial letter. You must submit it within 60 days of receiving the final denial (or up to 4 months under the federal program), and there is no filing fee. Your request should state what service was denied and briefly explain why you believe the denial was wrong.
Different states have different forms and submission methods, so check your denial letter first for state-specific instructions. For urgent situations where a delay in treatment could harm your health, you can request expedited review. The independent examiner must provide a written decision within 4 business days for expedited cases, compared to up to 60 days for standard reviews.
Finding Your State's External Review Process
The specific procedures for external review vary by state because each state's insurance commissioner oversees the program. To find your state's process, start with your insurance company's denial letter—it must include contact information for the external review program in your state. If you can't find that information, contact your state's insurance commissioner's office directly. Each state maintains resources or a hotline for external review information, and your commissioner can also direct you to the federal MAXIMUS/FERP program if needed.
Timeline and Decision
A standard external review decision must arrive within 60 days of your request. If you qualify for expedited review due to an urgent medical condition, the decision arrives within 4 business days. Once the decision is issued, it is final and binding on your insurance company. If the external reviewer agrees with you, your insurer must cover the denied service or correct any billing error. If the reviewer agrees with your insurer, you have exhausted this remedy, though you may retain the right to pursue legal action depending on your contract and state law.
Frequently Asked Questions
What's the difference between external review and internal appeal?
Internal appeals are decided by your insurance company itself within 30–60 days, and the insurer keeps final authority. External review uses an independent clinical expert unaffiliated with your insurer, and their decision is legally binding—your insurance company must follow it.
How much does it cost to file for external review?
It's free. There is no filing fee or cost to request an external review.
How long do I have to request external review after my claim is denied?
You have 60 days from the date you receive your insurance company's final denial letter. The federal MAXIMUS/FERP program allows up to 4 months.
What types of denials can go to external review?
External review covers denials involving medical necessity, treatment appropriateness, health care setting, level of care, treatment effectiveness, and experimental treatment—plus surprise billing disputes under the 2022 No Surprises Act.