If your health insurer denies a claim or a prior authorization, California law gives you the right to have that decision reviewed by an independent organization — not just the insurer's own internal appeals department. External review overturns insurer denials at significant rates, yet most policyholders never exercise this right.
External review is an independent review of a health insurance coverage denial by an organization with no financial relationship with your insurer. External reviewers are clinical experts who evaluate whether the denial was medically appropriate and consistent with applicable standards of care. The insurer is bound by the external reviewer's decision.
You can typically request external review after exhausting your insurer's internal appeal process — or in some cases, simultaneously with an expedited appeal. External review is available for: medical necessity denials; experimental or investigational treatment denials; and other coverage denials. The ACA established federal external review rights that apply to most health plans.
If your medical situation is urgent — your life or health could be seriously jeopardized by waiting — you can request an expedited external review. Expedited reviews must be completed within 72 hours. This right exists even before you exhaust internal appeals in life-threatening situations. Do not wait if the situation is urgent.
Your denial notice must include information about your right to external review and how to request it. Typically: submit a written request to your insurer or directly to the external review organization; include the denial notice, your treating provider's support, and clinical documentation; and meet the submission deadline (typically 120-180 days from the denial).
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Regulatory resource: California Department of Insurance — https://www.insurance.ca.gov. The Insurance Professor provides education only — not legal or insurance advice.