In Wisconsin, external review of an eligible denied claim runs through the federal HHS-administered process operated by MAXIMUS Federal Services, not a state-run program — Wisconsin runs a binding state independent-review program, but ACA external review defaults to the federal process. After internal appeals are exhausted, an independent federal reviewer decides, and the decision binds the plan. Expedited review is available for urgent care.
How the federal process works in Wisconsin
Eligible denials go to the HHS-administered federal external review, operated by MAXIMUS Federal Services. Wisconsin is among the states that use this federal process for ACA external review: Wisconsin runs a binding state independent-review program, but ACA external review defaults to the federal process.
After you exhaust the plan's internal appeals, an independent federal reviewer examines the denial and the medical record. The decision is binding on the plan — if it overturns the denial, the plan must cover the service.
Deadlines and what binds the plan
Under the federal standard, external review generally follows exhaustion of internal appeals and must be requested within four months of the final internal denial; expedited review can run in parallel for urgent care. The federal reviewer's decision binds the plan.
Federal process — for fully insured and self-funded alike
Frequently asked
Does Wisconsin run its own external review?
What's the deadline?
Primary sources: 45 CFR 147.136 (internal claims, appeals & external review); HealthCare.gov — external review process. General information, not legal or medical advice — confirm against the governing rule for the plan type.
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.