Appeal process · Escalation

External review (IRO): the independent appeal after the plan says no

When the plan upholds its own denial, external review hands the decision to an independent organization whose ruling the plan must follow. It is the most powerful step in the non-Medicare appeal ladder.

External review sends a denial to an Independent Review Organization (IRO) — a neutral third party — after the plan's internal appeals are exhausted. Under the Affordable Care Act's federal standard (45 CFR 147.136), most non-grandfathered plans, including many ERISA plans, must offer it, and the IRO's decision is binding on the plan. It applies to denials involving medical judgment and rescissions, not purely contractual exclusions.

Who qualifies and for what

External review is generally available for adverse benefit determinations that involve medical judgment (medical necessity, appropriateness, level of care, experimental/investigational determinations) and for rescissions of coverage. The plan type sets the path: ACA-governed and many ERISA plans use the federal or a comparable state external-review process; Medicare and Medicaid have their own separate ladders.

Plan type decides the process

ERISA self-funded plans are not subject to state insurance law — they use the federal external-review process. Fully insured plans typically use their state's process. Confirm the plan type before citing a framework.

The windows that matter

  • Internal appeals usually must be exhausted first (with limited exceptions for urgent care).
  • Standard external review: the request generally must be filed within four months of the final internal denial.
  • Expedited external review: available for urgent situations, with a decision typically within 72 hours.
  • The IRO's decision is binding — if it overturns the denial, the plan must provide coverage.

Frequently asked

Is the IRO decision really binding?
Yes. Under the federal external-review standard, a plan must comply with the IRO's determination. That is what makes external review the strongest non-Medicare step.
Can I skip internal appeals?
Generally no — internal appeals must be exhausted first, except in urgent cases where an expedited external review can run in parallel.
Does external review cover a flat exclusion?
Usually not. External review is for denials involving medical judgment and rescissions, not services the plan simply doesn't cover by contract.

Primary sources: 45 CFR 147.136 (internal claims & appeals and external review). General information, not legal or medical advice — confirm against the governing rule for the plan type.

Related guides

CO-204 · Not covered under the planExpedited & urgent appealsERISA plans & appeal rights

When the appeal has to be written, and cited

Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.

Appeal a denial →