External review in Florida: the federal HHS-administered process

Why Florida uses the federal process

Under the Affordable Care Act, a state either runs an external-review program that meets the federal minimum standards or its plans use the federal process instead. Florida's plans use the federal HHS-administered process. In practice, an eligible denial — one involving medical judgment, or a rescission of coverage — goes to an independent reviewer through the federal system, not a Florida agency. (An issuer may alternatively satisfy the requirement by contracting with accredited private review organizations.)

• Eligible denials: adverse determinations involving medical judgment, and rescissions of coverage.
• The reviewer is independent of the plan; the decision binds the plan.
• Self-funded ERISA plans also use a federal external-review pathway — so both eligible fully insured and self-funded plans here route federally.

The four-month deadline

Under the federal standard (45 CFR 147.136), the external-review request must be filed within four months of the date you receive the final internal adverse determination. Internal appeals generally must be exhausted first, though an expedited external review can run in parallel with the internal appeal for urgent care.

How to request federal external review

1. 1

   Exhaust the plan's internal appeals

   Complete the internal appeal — or, for urgent care, request expedited review in parallel.

2. 2

   Follow the denial notice into the federal process

   The plan's final denial explains how to request external review; the federal process is administered by MAXIMUS Federal Services. HealthCare.gov's external-review page is the durable consumer starting point.

3. 3

   An independent reviewer decides

   The reviewer examines the denial and the medical record; the decision is final and binding on the plan.

How fast — and what binds the plan

• Standard: a decision generally within 45 days of the request.
• Expedited (urgent): within 72 hours.
• The federal reviewer's decision is binding on the plan — an overturn means the plan must cover the service.

Where Florida still helps — and provider law

Florida doesn't run the external review, but the state Department of Financial Services' Division of Consumer Services operates an insurance consumer helpline (1-877-MY-FL-CFO) for complaints and questions. On the front end, Florida law standardizes prior authorization — insurers without an electronic PA process must use a standardized, roughly two-page form (Fla. Stat. § 627.42392) — and requires a written step-therapy exemption process, including no step therapy where the drug was approved under another plan within the prior 90 days (§ 627.42393). Those are useful levers before a denial ever reaches external review.