If your insurer upholds its denial after the internal appeal, you can usually take it to an external review — an independent third party (not your insurer) decides whether the service should be covered, and the insurer is bound by the result. For ACA plans you generally have up to 4 months (120 days) from the final internal denial to request it.
Before you write
You need the final adverse determination (the letter saying your internal appeal was denied). It should explain how to request external review and whether it goes through your state’s program or the federal HHS-administered process. Confirm the route and deadline on that letter.
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[External review body named in your final denial letter
- e.g. your state insurance department / external review org,
or the federal external review process]
Re: Request for external review
Member: [Name] Member ID: [number]
Plan: [insurer / plan name]
Claim number: [number] Date(s) of service: [dates]
Final internal denial date: [date]
To whom it may concern:
My health plan has issued a final denial after internal appeal for the claim
above, and I am requesting an independent external review of that decision.
Why the denial should be overturned:
[Summarize briefly - e.g. the service is medically necessary per my treating
physician and accepted clinical guidelines; attached records support this.]
Enclosed:
- The final internal denial / adverse determination letter
- My internal appeal letter and its enclosures
- Letter of medical necessity and medical records
- Any signed authorization form your process requires
Please confirm receipt and the expected decision date. If my health requires it,
I am requesting an EXPEDITED external review.
Sincerely,
[Your signature]
[Your printed name]
How to send it
Send within the deadline on your final denial letter (commonly 4 months for ACA plans). Use the exact body and address named there — some states run their own program; others use the federal process. Include the signed consent/authorization form if one is required, and keep copies.
Notes. A standard external review decision is generally due within about 45 days, and an expedited review within roughly 72 hours for urgent situations; if the reviewer sides with you, the insurer must cover the service. Exact timelines and the correct body depend on your plan and state, so follow your denial letter. General information, not legal or medical advice.