The rules behind the tool
| Plan type | Next level | Deadline | Decision time |
|---|---|---|---|
| Self-funded employer plan | Federal external review through the plan's contracted reviewers | 4 months after receiving the final denial | 45 days; 72 hours expedited |
| Insured employer or individual plan | State external review program, or the HHS-administered process in some states | At least 4 months (state rules may allow more) | 45 days; 72 hours expedited (federal standard) |
| Medicaid managed care | State fair hearing | 90 to 120 days from the plan's notice of resolution (state sets it) | Ordinarily 90 days; expedited 3 working days after the case file arrives |
| Medicare Advantage | Independent review entity (IRE), automatic | Nothing to file | Same clocks as the plan's reconsideration |
How do I use the external review request generator?
Choose the plan and review type named on the final denial notice, mark it expedited if waiting would seriously jeopardize the patient, and enter the decision date. The tool shows the deadline and the official pages, and drafts the request. List your reasons one per line; leave them blank to get bracketed prompts.
- 01Find the review type on the final denial notice: it must describe the external review process available, or the fair hearing process for Medicaid.
- 02Mark expedited only with a clinician's statement, or for external review when the denial concerns an admission, availability of care or a continued stay and the patient has not been discharged.
- 03Enter the date of the final decision and check the deadline the tool shows against the notice.
- 04Write the reasons as facts with dates: what the record shows against each criterion, what happened at lower levels of care, what the plan did not consider.
- 05Copy, download or print the letter, attach the enclosures it lists, and file it where the notice says, by a method that proves the date.
Which denials qualify for external review?
Under the federal rules, denials that involve medical judgment qualify: medical necessity, appropriateness, health care setting, level of care and effectiveness of a covered benefit, plus rescissions of coverage. Most behavioral-health level-of-care and continued-stay denials fit. Denials based only on eligibility under the plan's terms do not.
The rules are 29 CFR 2590.715-2719 for group health plans and 45 CFR 147.136 for insurers. For group health plans the federal process also covers whether the plan complied with the parity rules for nonquantitative treatment limits such as medical-management techniques, so a parity argument can go to the external reviewer too (see the parity checker).
Grandfathered plans generally do not have to offer external review, except for surprise-billing claims. Internal appeals usually come first, but if the plan fails to strictly follow the claims rules, the claimant is deemed to have exhausted them and can go straight to external review, unless the failure was minor and harmless.
An expedited external review is available when the standard timeframe would seriously jeopardize the claimant's life or health or ability to regain maximum function, or when the final denial concerns an admission, availability of care, continued stay or emergency services and the claimant has not been discharged. In urgent cases you can request it at the same time as an expedited internal appeal.
Federal or state external review: which one applies?
Insured coverage usually goes to the state's external review program, if the state's process meets the federal consumer-protection standards; otherwise the federal process applies. Self-funded employer plans usually use the federal process, contracting with independent review organizations. The final denial notice must say which process to use and how to start it.
In states without a qualifying process, insured plans use the HHS-administered process run by a federal contractor. HealthCare.gov explains how to file it online, by fax or by mail, and says the HHS process is free while state or contracted processes may charge up to $25. State programs often publish their own request form; the NAIC directory links each state insurance department.
Under the federal process the plan finishes a preliminary review within five business days, the assigned reviewer accepts additional information for ten business days after notifying you, and a standard decision comes within 45 days of the reviewer receiving the request. If it reverses the denial, the plan must provide coverage or payment.
File where the final denial notice says. A request sent to the wrong place does not stop the four-month clock.
How does a Medicaid state fair hearing request work?
After the managed care plan upholds the denial, the enrollee asks the state Medicaid agency for a fair hearing within the state's window, which is between 90 and 120 days from the plan's notice of resolution. If the plan missed its notice or timing rules, the enrollee can request a hearing without waiting for the plan.
The rules are 42 CFR 438.408(f) and Part 431, Subpart E. The enrollee or representative may examine the case file before and during the hearing (431.242). A standard hearing is ordinarily decided within 90 days of the date the plan appeal was filed, not counting the days taken to request the hearing; an expedited hearing within 3 working days of the agency receiving the case file (431.244(f)).
When the denial ends or reduces services the plan had authorized, the enrollee can ask to keep them going while the appeal and hearing are pending, under 42 CFR 438.420. The generator adds that request as an option; the cost may be recovered if the denial is upheld.
Do I need to request independent review in Medicare Advantage?
No. When a Medicare Advantage plan upholds its denial on reconsideration, in whole or in part, or misses its deadline, it must send the case file to the independent review entity itself. Expedited cases must be forwarded within 24 hours. The useful letter at this stage asks the plan to confirm the forwarding and send you the case file.
The forwarding rule is 42 CFR 422.590 and the independent review is 422.592. There is no CMS form for a Part C reconsideration request; plans take written requests and must accept oral requests for expedited reconsiderations. Plans may not require a specific appointment-of-representative form, although Form CMS-1696 is available.
If the independent reviewer also upholds the denial, the next level is a hearing before an administrative law judge, requested within 60 days of receiving the decision when the amount in dispute is at least $200 (2026 threshold).
What should an external review request include?
The request itself can be short: who is asking, the final denial date, the service and dates, what is disputed, why the denial is wrong and what you want. The weight is in the enclosures: the record for the dates at issue, a clinician letter, the criteria the plan applied, the internal appeal and the plan's responses.
- Both denial notices: the original and the final internal decision.
- The internal appeal and anything the plan sent back, including any new evidence or rationale.
- Medical records for each date at issue, not the whole chart.
- A treating clinician's letter that answers the criteria, plus a signed urgency statement if expedited.
- The criteria the plan applied, or proof you asked for them.
- The patient's signed authorization if a provider or other representative is filing.
A continued-stay denial headed to external review
Pinecrest Recovery (fictional) appeals a continued-stay denial for residential treatment under an insured employer plan. The plan upholds the denial in a final decision dated November 6, 2026. The patient remains in care.
The generator, set to state external review and expedited, shows a deadline of Monday, March 8, 2027: four months after November 6 is Saturday, March 6, which moves to the next business day. The program files the same day anyway, with the attending psychiatrist's statement that the patient has not been discharged and that stepping down now risks relapse.
The letter lists three dated points from the record and asks the plan to forward the claim file and the enclosures to the assigned reviewer.
Names, dates, payers and amounts are invented for illustration.
What a ClaimParrot packet adds
- If the internal appeal is upheld, an appeal packet for the external review level starts from the plan's final stated reason.
- Each packet holds the letter draft, the evidence checklist and the next-level deadline plan, checked by a person: $29, or $99 for level-of-care denials (pricing).
- Send the final decision's reason and a de-identified summary; Trust & security explains why no records are needed.
Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.
Frequently asked questions
How long do I have to request external review?
Under the federal process, four months after you receive the final internal denial. If that month has no matching date, use the first day of the fifth month; a weekend or federal holiday moves the deadline to the next business day. State programs must allow at least four months. The deadline calculator applies all three rules.
Does external review cost anything?
HealthCare.gov says the HHS-administered process has no charge and that state or contracted processes may charge up to $25. The federal process for self-funded plans may not charge the claimant a filing fee.
Can a provider request external review for the patient?
Usually as the patient's authorized representative, with a signed authorization; the plan or state may have its own form. For Medicaid fair hearings and Medicare Advantage appeals, check the representative rules on the notice. Enclose the authorization with the request so it isn't sent back.
Is the external reviewer bound by the plan's criteria?
The independent reviewer considers the record, the plan's terms and appropriate clinical standards, and is not limited to the plan's internal conclusion. That is why the clinician letter should answer the criteria the plan cited and explain the clinical reasoning in plain terms.
What if the plan never decided my internal appeal?
Under the federal rules, a plan that fails to strictly follow the claims procedures can be treated as having exhausted the internal process, which lets you request external review right away. In Medicaid managed care, a plan that misses its notice or timing rules lets the enrollee request a state fair hearing directly.
Primary sources and references
- 29 CFR 2590.715-2719: internal claims, appeals and external review (group health plans) · eCFR (National Archives) · checked
- 45 CFR 147.136: internal claims, appeals and external review (issuers, individual market) · eCFR (National Archives) · checked
- External review: how to request it, deadlines and decision times · HealthCare.gov (CMS) · checked
- External appeals: consumer facts on the federal process · CMS · checked
- 42 CFR 438.408: appeal resolution, notice and state fair hearing · eCFR (National Archives) · checked
- 42 CFR 431.244: fair hearing decisions and timing · eCFR (National Archives) · checked
- 42 CFR 438.420: continuation of benefits during an appeal · eCFR (National Archives) · checked
- 42 CFR 422.590: reconsideration timeframes and forwarding to the IRE · eCFR (National Archives) · checked
- Review by the Part C independent review entity · CMS · checked
- Appeals in Medicare health plans · Medicare.gov · checked
- Medicare appeals: amount in controversy thresholds for 2026 ($200 for an ALJ hearing) · Federal Register · checked
- Form CMS-1696, Appointment of Representative · CMS · checked
General information, not legal or medical advice. The denial notice, the plan documents and state law control; state law can give more time or more rights than the federal floor shown here. Read our editorial policy.
Doing this for every denial in the queue?
Send one de-identified denial and get the appeal letter draft, evidence checklist and deadline plan back, checked by a person before it reaches you. $29 per appeal packet, $99 per level-of-care packet; your first packet is free.