New Jersey external review (IRO) process
After internal appeal exhaustion, New Jersey offers external review by an Independent Review Organization. The IRO decision binds the plan.
When external review applies
Required by ACA §2719 for non-grandfathered commercial plans. Federal IRO process applies to self-funded ERISA plans. State IRO process applies to fully-insured plans in $New Jersey.
Key steps
- Exhaust internal appeal first (one or two levels depending on plan)
- Receive final internal denial notice — it must state external review rights + how to request
- Request external review within 4 months (federal floor) — $New Jersey-specific instructions in the denial
- Submit clinical documentation supporting your appeal to the IRO
- Wait for IRO decision: 45 days standard, 72 hours expedited
- If IRO overturns, plan MUST cover the service
New Jersey contact
Frequently asked questions
How do I request external review in New Jersey?
After your internal appeal is exhausted, file the external review request with New Jersey's designated IRO process. Federal floor: 4 months from final internal denial. New Jersey-specific instructions are in your denial notice, on the state insurance department website (https://www.nj.gov/dobi/), or via the Consumer Assistance Program. Self-funded ERISA plans use the federal IRO process; fully-insured commercial plans use the state IRO process.
Is the IRO decision binding?
Yes — if the IRO overturns the plan's denial, the plan MUST cover the service. ACA §2719 makes external review decisions binding on the plan.
Can I file expedited external review?
Yes, for urgent cases where standard timelines would jeopardise life, health, or function. Expedited decisions: 72 hours.
Does external review cost anything?
Most state IRO processes are FREE to consumers. Plans pay the IRO fee.
Other New Jersey resources
Sources
File with New Jersey insurance department
New Jersey's designated external review process: https://www.nj.gov/dobi/consumer.htm
Get started →Contact: hello@denialhelp.com