External review explained

What external review actually is

When your insurer upholds its own denial through the internal appeal process, you get one more chance: an independent review organization, unaffiliated with your insurer, examines the case and issues a decision. That decision binds the insurer. They can't overrule it, appeal it internally, or simply ignore it. This is different from an internal appeal, where the same company that denied you is also the one deciding whether it was right to do so.

External review has a narrower scope than an internal appeal. It generally covers medical necessity, appropriateness of care, and experimental-or-investigational determinations, the kinds of clinical judgment calls where an outside medical opinion actually changes the analysis. It typically does not reach flat contractual exclusions, like a plan that simply doesn't cover a category of treatment at all. If your denial is a coverage exclusion rather than a clinical judgment, external review usually can't help, and it's worth knowing that before you spend months waiting on a decision that won't go anywhere.

Who qualifies

You generally need to have exhausted your internal appeal first, meaning you filed it and the insurer upheld the denial. There's an exception: if the insurer missed its own procedural deadlines or skipped a required step during your internal appeal, that failure can sometimes count as "deemed exhaustion," letting you move to external review (or even court) without waiting for a final internal decision. This is one more reason to track your insurer's deadlines as closely as your own.

Which organization reviews your case depends on your plan type. If your employer self-funds its health plan, you're in the federal ERISA process, using either plan-contracted independent review organizations or the HHS-administered process run through Maximus. If you have an ACA marketplace plan or a fully-insured employer plan, your state runs the external review process instead. Ask your HR department whether your plan is self-funded if you're not sure which applies to you.

The deadline: 4 months

You have four months from the date of your final internal denial to request external review. That clock starts the day the insurer sends its internal appeal decision, not the day you receive it or the day you get around to reading it, so don't let mail delays eat into your window. As always, check the specific deadline on your denial letter, since it governs over this general figure.

Standard external review decisions come back within 45 days. If your situation is urgent, meaning a standard timeline would seriously jeopardize your life, health, or ability to regain maximum function, you can request expedited review instead, and a decision comes back within 72 hours.

Why the overturn numbers matter

External review exists because internal appeals, decided by the same company that denied the claim in the first place, overturn denials at a meaningfully lower rate than independent review does. The actual numbers vary by state and program, but the direction is consistent.

None of these numbers are a promise about your case. Every denial and every plan is different, and no one can tell you in advance how your specific appeal will come out. What they do tell you is that an independent reviewer, without your insurer's financial interest in the outcome, reverses denials often enough that skipping this step because "it probably won't work" is usually the wrong call.

If the federal portal is down

As of mid-2026, the HHS-administered federal external review process (the Maximus FERP portal) has had reported outages. If you're in the federal ERISA track and the portal isn't accepting your request, you have two fallbacks: filing through the plan-contracted IRO route instead, or filing a complaint with the Department of Labor's Employee Benefits Security Administration at 1-866-444-3272. Don't let a broken portal become a missed deadline. Document the outage and pursue the alternate path immediately.

Where this fits in the bigger process

External review is the second half of a two-part process. If you haven't filed your internal appeal yet, start with our full step-by-step appeal guide, which covers deadlines, what to request from your insurer, and what goes in the appeal letter. If you're on Medicare Advantage, your path to independent review is automatic rather than something you request. That process is covered separately in our Medicare Advantage appeal guide.