Why request an External Review?
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 (sometimes called "final" or "binding" review). In an External Review, your case will be re-evaluated by specialty reviewers to determine whether the disputed claim should be covered.
Who can request an External Review?
You or your authorized representative (including your treating provider) may file a request for an External Review. That request should be filed with either your health insurance carrier or an 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 MCN is selected as the Independent Review Organization for your case the review will proceed as follows:
- The insurance carrier is required to send us all of the materials they used to determine your coverage denial.
- You will also receive instructions on where to supply additional information for consideration in your case.
- Relevant information may include: your medical records, your treating provider’s recommendations, reports from appropriate health care professionals and other documents submitted by the carrier, you, and/or your treating provider, your health insurance plan text, appropriate practice guidelines, and any applicable clinical review criteria developed and used by your plan.
- All of your medical documents will be handled in accordance with the strictest federally mandated patient privacy laws.
Reviewer Selection/ Reviewer Decisions/ Conflict of Interest
When all supporting documentation has been received, MCN will assign a specialty reviewer to your case. All of our reviewers go through a rigorous credentialing process, following URAC-approved standards, and are then vetted for any potential conflict 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 expertise 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.
What happens next?
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 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.
Other resources to help you
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.