An Alabama denial is decided outside Alabama

Open now, and a deadline extension runs to October 2, 2026

The federal process was unavailable for part of this summer. CMS closed the HHS-administered Federal External Review Process between July 1 and August 3, 2026 and reopened it on July 31, 2026, and it has extended the filing deadline for people the closure shut out.

• If you could not request external review between July 1, 2026 and August 3, 2026, you may be eligible — and if you are, you have until October 2, 2026 to request it.
• The extension also reaches any state: it covers a self-insured non-Federal governmental health plan that uses the federal process, wherever the plan is.
• If you submitted a request before July 1, 2026, you do not need to resubmit or send anything further now.
• If you already received a final decision through the federal process, the extension does not apply to you.

On appeal, a same-specialty physician decides

Alabama's own utilization review law still governs a fully insured plan here even though external review runs federally. On appeal, all determinations not to certify an admission, service or procedure as necessary or appropriate must be made by a physician in the same or a similar general specialty as typically manages the condition, procedure or treatment at issue. Where the service is chiropractic and the attending chiropractor, enrollee or designee has appealed, a chiropractor must review the case.

There is no state program to appeal to

The starting point is structural. Alabama does not operate an ACA-compliant state external-review program, so eligible denials default to the federal process administered by HHS. The practical consequence is that the Department of Insurance in Montgomery is not the venue — writing to it as though it were the appeal body costs time the deadline does not give back.

Where the request actually goes

MAXIMUS Federal Services, Inc. performs the administrative functions of external review on behalf of HHS, and also provides technical assistance to people filing requests. There are several routes in, and the federal portal is the fastest of them.

• Online through the federal external appeals portal at externalappeal.cms.gov.
• By telephone on 1-888-866-6205 to request a form.
• By fax to 1-888-866-6190.
• By mail to MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534.

45 days, and 72 hours

The federal process decides a standard external review no later than 45 days after the request is received, and an expedited review no later than 72 hours after receipt. Those are the same figures a Florida, Georgia, Texas or Wisconsin case runs on, because it is the same process — which means national guidance about the federal timeline is directly applicable here in a way that state-specific guidance usually is not.

Four months, from the final internal denial

The federal framework sets the window, and it is the same one that applies to marketplace and other non-grandfathered coverage nationally: a request for external review must be filed within four months after the date of receipt of the notice of final internal adverse determination. Because Alabama has no separate state deadline layered on top, there is nothing shorter to catch you out — but there is also no state extension to fall back on.

• Filing window: 4 months after receipt of the final internal adverse determination.
• Standard decision: no later than 45 days after the request is received.
• Expedited decision: no later than 72 hours after the request is received.

What the state department can still do

The Department of Insurance is not powerless; it is just not the appeal body. Its Consumer Services Division, reachable on 334-241-4141, is the right contact where an insurer is not cooperating with the appeals process itself — refusing to acknowledge an internal appeal, failing to issue a final determination, or otherwise obstructing the path to external review.

Alabama is a direct-enforcement state

The federal role does not end at the appeal. CMS has a statutory obligation under sections 2723 and 2799B-4 of the Public Health Service Act to directly enforce any provision a state does not substantially enforce, and Alabama is currently among the direct-enforcement states, alongside Missouri, Oklahoma, Tennessee, Texas and Wyoming. Federal market conduct examinations of issuers may be conducted under 45 CFR 150.313.

• Under a collaborative enforcement agreement, the state performs policy form review, investigations, market conduct examinations and consumer assistance.
• Where the state finds a potential violation and cannot obtain voluntary compliance, it refers the matter to CMS for possible enforcement action.

Finish the internal appeal properly

Because the external stage is federal and procedural, the internal appeal carries more weight than usual. The federal reviewer works from the record the plan built, and eligibility depends on a final adverse determination existing at all. An internal appeal answered vaguely, or never answered, is a problem to fix before the request goes in — not something the external reviewer will correct.

For Alabama practices

Point the paperwork at the right target from the start. Clinical disagreement goes to the federal process through the portal or by fax, with the final adverse determination attached. Conduct problems go to Consumer Services in Montgomery. And because the deciding reviewer is a federal contractor with no local knowledge of the practice, the plan or the referral pattern, everything the argument depends on has to be inside the submission.