Alaska

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity
• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical judgment
• Claim denials based on the failure to meet the internal appeals deadlines

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Retirements and Benefits section of the Alaska Department of Administration

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 21 working days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Arizona

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All utilization review decisions

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 20-36 working days
• For urgent cases, 3-9 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Arkansas

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity
• Claim denials based on experimental or investigational exclusion

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Arkansas Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived if this will create a financial hardship, or refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For non-urgent cases, 45 working days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

California

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on urgent care or emergency services
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the California Department of Managed Health Care

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 working days
• For urgent cases, 3 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Colorado

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Colorado Division of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 working days
• For urgent cases, 7 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Connecticut

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity
• Claim decisions not to certify an admission, service, procedure or extension of stay

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Connecticut Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived if this will create a financial hardship, or refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• 30 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Delaware

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Delaware Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 45 working days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

District of Columbia

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, except in case of emergency

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the District of Columbia Department of Health

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Florida

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity
• Claim denials based on health care quality
• Claim denials based on excluded benefits or unauthorized services
• Claim denials for emergency services
• Claim denials based on billing issues

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Florida Agency for Healthcare Administration

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 165 days
• For urgent cases, 65 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Georgia

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on excluded benefits
• Concerns related to health care quality, access to services and required disclosures

Who can file an external review request?

• You – the covered person, your legal guardian or your parent

Where do I send my request?

• Contact your health plan or the Georgia Department of Community Health

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For non-urgent cases, 15 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Hawaii

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Hawaii Department of Commerce & Consumer Affairs

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For non-urgent cases, 90 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Illinois

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• For HMO coverage - No
• For all other coverage - Yes

What types of disagreement qualify for external review?

• For HMO coverage - Claim denials based on medical necessity
• For all other coverage – Claim denials:
  • Based on medical necessity,
  • For specific tests or procedures,
  • For referrals to specialists, or
  • For hospitalization length of stay requests

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Illinois Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• 5 days after the external review organization receives all necessary information.

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Indiana

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Indiana Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes – up to $25

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 15 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Iowa

Iowa Code §§514J.1 to 514J.15 and Iowa Admin. Code §§191-76.1 to 191-76.9
Effective 2000
Last amended 2006

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Iowa Division of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived for good cause, or refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, up to 45 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Kansas

Kan. Stat. Ann. §§40-22a13 to 40-22a16
Effective 2000

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Consumer Assistance Division at the Kansas Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 7 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Kentucky

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity
• Claim denials based on limited or excluded benefits

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Division of Health Insurance Policy and Managed Care at the Kentucky Office of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived if this will create a financial hardship, or refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $100

How long does the external review process take?

• For non-urgent cases, 21 days
• For urgent cases, 24 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Louisiana

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, unless waived or in case of emergency

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Office of Health Insurance at the Louisiana Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Maine

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, except in case of emergency

What types of disagreement qualify for external review?

• Claim denials based on medical necessity
• Claim denials based on pre-existing condition exclusions
• Claim denials based on experimental or investigational exclusion

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan and the Consumer Health Care Division at the Maine Bureau of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Maryland

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, except in case of emergency

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Maryland Insurance Administration

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, up to 45 working days
• For urgent cases, 24 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Massachusetts

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Office of Patient Protection as the Massachusetts Department of Public Health

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived if this will create a financial hardship

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, up to 75 days
• For urgent cases, 5 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Michigan

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Benefit Inquiry Section of the Michigan Office of Financial and Insurance Services

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 14 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Minnesota

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Minnesota Department of Health (for HMO coverage) or the Minnesota Department of Insurance (for all other coverage)

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Waived if this will create a financial hardship

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 40 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Missouri

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Missouri Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• 20 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Montana

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Montana Department of Public Health and Human Services

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Nevada

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Nevada Governor's Office of Consumer Health Assistance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

New Hampshire

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the New Hampshire Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $400

How long does the external review process take?

• For non-urgent cases, 20 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

New Jersey

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials for covered services

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Office of Managed Care at the New Jersey Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25, which may be reduced to $2 in cases of financial hardship

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 48 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

New Mexico

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All utilization review decisions

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the New Mexico Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 20 working days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

New York

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the New York Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes – up to $50. Waived if this will create a financial hardship, or refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

North Carolina

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the North Carolina Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 45 days
• For urgent cases, 4 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

North Dakota

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the North Dakota Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• Not specified

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Ohio

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, unless waived

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Ohio Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• For experimental or investigational exclusion cases, No
• For medical necessity cases, Yes - $500

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 7 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Oklahoma

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Oklahoma Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes – up to $50. Refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $1,000

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

Oregon

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity
• Claim denials for an active course of treatment

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Oregon Insurance Division

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 3 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Pennsylvania

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• No

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Pennsylvania Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes – up to $25

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• Approximately 75 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Rhode Island

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Rhode Island Department of Health

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 10 working days
• For urgent cases, 48 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card.

South Carolina

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, unless waived

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the South Carolina Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For non-urgent cases, 45 days
• For urgent cases, 3 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Tennessee

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Tennessee Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $50

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $500

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 5 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Texas

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, except in an emergency

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person, your health plan, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Texas Department of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, 15 days after the external review organization receives all necessary information
• For urgent cases, up to 8 days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Utah

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, unless waived

What types of disagreement qualify for external review?

• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Utah Insurance Department

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, up to 60 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Vermont

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on pre-existing conditions
• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity
• Claims denials for mental health services

Who can file an external review request?

• You – the covered person, your health care provider, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Vermont Department of Banking, Insurance Securities and Health Care Administration

Do I have to pay a fee to file a request for external review? If so, how much?

• For mental health services cases, No
• For all other cases, Yes – up to $25. Waived if this will create a financial hardship

Is there a minimum dollar amount for external review? If so, how much?

• For mental health services cases, No
• For all other cases, Yes - $100

How long does the external review process take?

• For mental health services cases, not specified
• For all other non-urgent cases, 30 days
• For all other urgent cases, 48 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Virginia

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All utilization review decisions

Who can file an external review request?

• You – the covered person, or your health care provider

Where do I send my request?

• Contact your health plan or the Virginia Bureau of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes – $50. Waived if this will create a financial hardship

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $300

How long does the external review process take?

• For non-urgent cases, 30 working days after receipt by the external review organization of all necessary information
• For urgent cases, up to 11 working days

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Washington

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the Washington Office of the Insurance Commissioner

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• No

How long does the external review process take?

• For non-urgent cases, up to 20 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

West Virginia

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes

What types of disagreement qualify for external review?

• Claim denials based on experimental or investigational exclusion
• Claim denials based on medical necessity

Who can file an external review request?

• You – the covered person

Where do I send my request?

• Contact your health plan or the West Virginia Insurance Commission

Do I have to pay a fee to file a request for external review? If so, how much?

• No

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $1,000

How long does the external review process take?

• For non-urgent cases, up to 45 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

• You can also contact your health plan for additional information by calling the toll-free number listed on your ID card

Wisconsin

Wis. Stat. §632.835 and Wis. Admin. Code Ins. §18.11-12
Effective 2000
Last amended 2005

State External Review Requirements

Must I complete my health plan's review process before I request an external review?

• Yes, unless waived or in case of emergency

What types of disagreement qualify for external review?

• All claim denials

Who can file an external review request?

• You – the covered person, or someone you authorize to file on your behalf

Where do I send my request?

• Contact your health plan or the Wisconsin Office of the Commissioner of Insurance

Do I have to pay a fee to file a request for external review? If so, how much?

• Yes - $25. Refunded if your claim is approved

Is there a minimum dollar amount for external review? If so, how much?

• Yes - $250

How long does the external review process take?

• For non-urgent cases, 30 days
• For urgent cases, 72 hours

Additional Information

Your state's insurance department can provide more information and instructions on how to file a request for external review. Often this information is posted on the department's Web page. Additionally, your state may have an office of consumer advocacy that can provide you with additional information concerning your state's specific external review laws and procedures.

• View contact information for state departments of insurance and consumer advocate offices.

You can also contact your health plan for additional information by calling the toll-free number listed on your ID card