External review (IRO)

What it is

External review is binding review of a denial by an Independent Review Organization (IRO) — an organization independent of the plan, certified at the federal or state level, that employs qualified medical reviewers. The IRO's decision is binding on the plan: if the IRO overturns the denial, the plan must cover the service. Available for most non-grandfathered plans after internal appeal exhaustion.

Who can use it

Plan members and their designated representatives. Providers can submit clinical documentation but cannot independently initiate external review without patient consent.

When to use it

After internal appeal is exhausted (one or two levels depending on the plan). Some plans require both levels; some allow direct external review after one. Urgent cases can request expedited external review concurrently with internal appeal.

Steps

1. Confirm internal appeal exhausted. Check the final internal denial notice — it should state external review eligibility and how to request it.
2. Choose state or federal external review. Self-funded ERISA plans use the federal external review process (HHS-administered, IRO selected from CMS list). Fully-insured plans use the state external review process where the state has one meeting NAIC/federal standards.
3. Request within 4 months. Federal floor is 4 months from final internal denial.
4. Submit clinical evidence. The IRO reviews the medical record. Include chart notes, guidelines, and your appeal narrative.
5. Wait for the IRO decision. Standard: 45 days. Expedited: 72 hours. Decision is binding on the plan.

Key deadlines