Florida hands external review to the federal process

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.

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.

Two federal routes — read which one your denial names

A Florida plan can satisfy the federal requirement in one of two ways, and they do not feel the same from the outside. Under 45 CFR 147.136(c) it can send eligible cases to the HHS-administered process run by MAXIMUS Federal Services, or it can contract with accredited independent review organizations and route them there instead. Either way the reviewer is independent of the plan and the decision binds it — but the address, the forms, and the contact you need come from the final denial notice, not from a state agency.

Florida still regulates the front end

Not running the external review does not mean Florida is absent from utilization management. State law reaches the stage before the denial, and two provisions are worth knowing.

On prior authorization, Fla. Stat. § 627.42392 — in force since January 1, 2017 — requires an insurer that has no electronic prior-authorization process to use a standardized form of no more than two pages, adopted through the Financial Services Commission. It is a limit on how much paperwork a plan can demand before it will consider an authorization request.

Step therapy, and the 90-day rule worth remembering

Fla. Stat. § 627.42393 requires insurers to publish a written step-therapy exemption procedure with a request form, to decide requests within a reasonable time, to give a written clinical rationale when they deny, and to allow an appeal. It also carries a specific rule that resolves a common situation:

• Step therapy cannot be required where the drug was approved under another health plan within the previous 90 days.
• The insurer's exemption procedure and its request form must be published, not supplied on request.
• A denial of an exemption must come with a written clinical rationale, and it must be appealable.

Where to get help in Florida

Although the review itself is federal, the state Department of Financial Services' Division of Consumer Services runs the insurance consumer helpline — 1-877-MY-FL-CFO — along with an online complaint portal, and it is the right place for a complaint about how a Florida-regulated insurer handled a claim. The Office of Insurance Regulation supervises insurers but directs consumer complaints to that division.

What a Florida denial notice must contain

Before the clinical argument begins, check the notice against Fla. Stat. 641.51. Florida requires the written notification of an adverse determination to include the utilization review criteria or benefits provisions relied on, to identify the physician who rendered the determination, and to be signed by an authorized representative of the organization or by that physician.

That gives a practice something concrete to test on paper. A notice that names no physician, or that asserts criteria without stating them, is deficient on the face of the statute — and a request that the plan supply both is a reasonable, narrow ask that costs nothing to make and frequently produces the document the appeal actually needs.