External review
Binding review by an Independent Review Organization after internal appeal is exhausted. The IRO decision binds the plan.
External review is conducted by an Independent Review Organization — a CMS-certified or state-certified organization independent of the plan. The IRO employs qualified medical reviewers and renders a binding decision: if the IRO overturns the denial, the plan must cover the service. Required by ACA §2719 for most non-grandfathered plans. Standard external review: 45 days; expedited: 72 hours.
Frequently asked questions
What is external review?
External review is conducted by an Independent Review Organization — a CMS-certified or state-certified organization independent of the plan. The IRO employs qualified medical reviewers and renders a binding decision: if the IRO overturns the denial, the plan must cover the service. Required by ACA §2719 for most non-grandfathered plans. Standard external review: 45 days; expedited: 72 hours.
Related terms
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