Definition
External Review
An independent review of an insurance denial by a third party whose decision is binding on the insurer.
External review is an independent review of an insurance coverage denial conducted by an impartial reviewer who is not employed by your insurer. For ACA-governed plans (marketplace and most individual plans), the right to external review is guaranteed under PHS Act § 2719 and 45 CFR § 147.136 — and the external reviewer's decision is binding on the insurer. For ERISA-governed employer plans, external review rights depend on the state and plan type; self-funded employer plans may be exempt from state external review mandates. External review is typically available after your internal appeal is denied and represents a significant backstop: consumers win external review decisions at a meaningful rate, and the insurer cannot simply ignore the outcome.
Related terms