A decision your plan does not get to make.

Last updated August 17, 2026

What external review is

An internal appeal asks your insurance company to look again at its own decision. External review takes the same question to reviewers outside the company: independent organizations whose clinical reviewers are screened for conflicts of interest and are not paid based on the outcome. Neither your plan nor My Live Health picks them, and neither can lean on them.

The point of the program is that the party paying the claim should not have the final word on whether the claim is payable. When the external reviewer overturns a denial, the plan must provide the coverage or make the payment.

Who runs it

Most states run their own external review program through the state insurance regulator, using independent review organizations it has approved. Where a state program does not apply, a federal process administered by the U.S. Department of Health and Human Services fills the gap. Some employer plans use a private accredited process that has to meet the same federal standards.

You do not have to work out which one covers you. Your plan is required to tell you, in the final denial notice, which program applies and how to reach it. If the notice does not say, call the number on your ID card and ask for it in writing.

What kinds of denials qualify

External review generally covers denials that turn on clinical judgment rather than plain contract math, including:

• Denials based on medical necessity, appropriateness, health care setting, or level of care.
• Denials that call a treatment experimental or investigational.
• Denials of effectiveness for the condition being treated.
• Rescission of coverage, meaning coverage that was cancelled retroactively.

Denials that rest on something else, such as a service the contract simply does not cover, or a premium that went unpaid, are often outside the program. Eligibility rules vary by plan type and by state, so if you are not sure, request the review anyway and let the program decide.

Deadlines

There is a filing window that starts when the plan issues its final internal denial, commonly four months, and it is stated on the notice you receive. Once the request is accepted, the reviewer has a fixed period to decide, and an expedited track exists for situations where the standard timeline would seriously jeopardize your health, your life, or your ability to regain maximum function. In an urgent case you can usually ask for expedited external review at the same time as the internal appeal rather than waiting for it to finish.

Treat the date on the denial notice as the clock. Missing the filing window is the most common way a strong case ends.

What it costs

External review is free or close to it. Where a filing fee exists at all it is small, refundable if you win, and waived for hardship. You do not need a lawyer, and you are not required to have a representative, though you may name one.

Making the request count

• Include the final denial notice, the claim or reference number, and your member ID.
• State in one sentence what you want covered and why the denial is wrong.
• Attach a letter of medical necessity from your treating clinician. This is the single most useful document in the file.
• Add chart notes, imaging, test results, and any published clinical guidance that supports the treatment.
• Ask your plan for the criteria it applied, which it must give you free of charge, and answer those criteria directly.
• You can usually submit additional information after filing. Send it as soon as you have it rather than holding the request.

Medicare, Medicaid, and other coverage

Medicare Advantage and Part D have their own multi-level appeal system defined by Medicare, in which a review by an independent entity outside your plan happens automatically at a set stage, followed by further levels if needed. For questions you can call 1-800-MEDICARE, 24 hours a day, 7 days a week, TTY 1-877-486-2048.

Medicaid and CHIP use the state fair hearing process rather than the commercial external review program, with its own deadlines and, if you file quickly enough, the possibility of keeping benefits in place while the appeal is decided. Start with your state Medicaid agency through the state information page.

Coverage through an employer follows federal claims and appeals rules. Self-funded plans are generally outside state insurance regulation and use a federal or private accredited external review process instead. Your summary plan description names it.

Products that are not major medical coverage, such as short term plans and some supplemental products, may not carry these rights at all. That is one of the trade-offs described on the plan disclosures page.

Where to get help

Your state department of insurance can tell you whether its program applies to your plan and how to file, and many states fund consumer assistance programs that will help you assemble the request. Federal guidance on appealing an insurance company decision, including external review, is published at HealthCare.gov.

You can also call us at (833) 741-1902. We cannot decide your case and we are not a party to it, but a licensed agent can read the denial with you, explain what the plan actually said, and point you at the right program. Before you get here, work through filing a grievance or appeal.