An external review is your appeal to an independent third party — an Independent Review Organization (IRO) — after your insurer’s internal appeal upholds the denial, or after internal appeals are exhausted. The IRO is not part of your plan, and for ACA-compliant plans its decision is generally binding on the insurer. This letter requests that review and attaches your appeal record. You generally must request it within 4 months of the final internal denial, but the controlling deadline and instructions are on your final denial letter, so check it first.
Before you appeal
- Your final internal denial letter, which should describe your external-review rights and deadline.
- The original denial and EOB, and the internal appeal you filed.
- Any clinical records, provider letters, and guidelines you submitted, plus anything new that supports your case.
- The plan’s medical-necessity criteria or rules it relied on (request these if you do not have them).
- Your member ID, group number, claim number, the date(s) of service, and the denial dates.
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[Insurer / State external-review program / HHS-administered process]
[Address from your final denial letter]
Re: Request for external (independent) review
Member: [Name] Member ID: [number] Group #: [number]
Claim number: [number] Date(s) of service: [dates]
Internal denial date(s): [dates] Denial reason/code: [as stated on the letter]
To Whom It May Concern:
I am requesting an external review of the denial identified above by an
Independent Review Organization. My internal appeal has been [upheld / treated
as exhausted], as shown in the enclosed final denial letter, and I am now
asking for an independent review of the plan's decision.
The denied service should be covered for the following reason(s):
[Summarize briefly: the service is medically necessary as documented by my
provider; the denial conflicts with recognized clinical guidelines for my
condition; the plan misapplied its own criteria; or the information relied on
was incomplete. Keep this short and point to the enclosed record.]
I ask the reviewer to overturn the denial and direct the plan to cover this
service.
Enclosed in support:
- Final internal denial letter
- Original denial / EOB
- My internal appeal and all supporting records
- Letter(s) of medical necessity and clinical guidelines, if any
If a delay would seriously jeopardize my health, I am also requesting an
expedited external review.
Please confirm receipt and the expected decision date in writing.
Thank you,
[Your signature]
[Your printed name]
How to send it
Follow the external-review instructions on your final denial letter. The request usually goes through your insurer, which forwards it to either your state’s external-review program or the federal HHS-administered process, depending on your plan type. Submit within the deadline (generally 4 months of the final internal denial), use certified mail or the official channel, and keep a dated copy. A standard external-review decision is generally due within about 45 days; an expedited review for urgent situations is generally within about 72 hours.
Notes. Under the ACA, external review by an IRO is available after internal appeals, and for non-grandfathered plans the IRO’s decision is generally binding on the insurer. The path (state program vs. federal HHS-administered process) depends on whether your plan is state-regulated or self-funded — see which appeal process applies. Track your dates with appeal deadlines, make sure your internal appeal is done first, and consider a parallel state insurance department complaint if the process itself was mishandled. This is general information, not legal, medical, or insurance advice.