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When your health insurance carrier denies a claim for medical care or treatment, they are required by law to provide you with a process to appeal the denial. If you complete your carrier’s internal appeals process and your claim is still denied, your case may be eligible for an External Review. In an External Review, your case will be re-evaluated by specialty reviewers to determine whether the disputed claim should be covered.
You or your authorized representative (including your physician) may file a request for an External Review. That request should be filed with either your health insurance carrier or applicable state agency. Information on how to file is required by federal law to be included with the final claims denial decision from your insurer. External Reviews are conducted by Independent Review Organizations like MCN and are generally assigned on a rotating or random basis to ensure impartial results.
When all supporting documentation has been received, MCN will assign a specialty reviewer to your case. All of MCN’s reviewers go through a rigorous credentialing process and are then vetted for any potential conflicts of interest. The reviewer(s) assigned to your case will be matched based on the specialty of your treating provider and their experience treating the medical condition(s) in question.
In addition to any received documents, the specialty reviewer will use their expert opinion and additional reference materials at their discretion to make a decision.
Our reviewers are not bound by any of the decisions or conclusions made by the health insurer during the internal appeals process and will review all the elements of your case from scratch.
After your External Review is complete, both you and your health insurance carrier will receive written notice of our specialty reviewer’s decision.
External Review decisions are legally binding.
However, we and our specialty reviewers cannot be held liable in any way for the outcome of your review. If our specialty reviewer determines that your benefit denial should be overturned, your health insurance carrier is responsible for immediately authorizing coverage or payment for the claim. If our specialty reviewer upholds the benefit denial you may still have the right to pursue a judicial review of your case.
If you have any further questions about your rights or need assistance, you can contact the Employee Benefits Security Administration (EBSA) at 866.444.3272 or the Center for Consumer Information and Insurance Oversight (CCIIO) at 877.696.6775.