How and When to file an External Review

How

There are 4 PDF forms that will allow you to type information into the form. You should complete the required forms, print them at your printer, then send the completed and signed form(s) to the address at the bottom of the form. The forms are:

• External Review Request form - Required in all instances.
• Health Care Provider Certification form - use if you are filing for an Expedited or Experimental/Investigational Denial Review; your Physician will have to complete this form
• Appointment of Authorized Representative form - use to provide an appointment to another person for the review
• External Review Appeal to Director form - use to file a final appeal of a decision made pursuant to the Health Carrier External Review

When

• If you disagree with a health carrier's determination, regarding medical necessity, experimental/investigational, pre-existing condition or rescission of health coverage you may file a Request for External Review with the Illinois Department of Insurance.
• You must first exhaust your internal appeal rights before requesting an external review except in urgent circumstances.
• You must file for an external review within 4 months from the date of written notification that the internal appeal process has been exhausted.

More Information

House Bill 0224 gives covered persons the right to apply for an External Review for the denial, reduction, termination or failure to make payment under the health carrier's benefit plan for the following reasons:

1. the service was not "Medically Necessary"; or
2. the service is considered "Experimental/investigational"; or
3. the condition is "Pre-existing"; or
4. your coverage is being rescinded (voided) for a reason other than non-payment of premium or contributions;

You are not eligible for an external review under Illinois law if:

• you are covered by a self insured employer or self insured union plan unless your employer or union plan has opted for the state process;
• you are covered by a group plan which is issued in another state;
• the coverage is through Medicare, Medicaid, Federal Employees Health Benefits Program; Tricare or other military coverage;
• the coverage is for a specified disease (such as cancer only); specified accident or accident only, credit, dental, disability income, hospital indemnity, long-term care, vision, or other limited supplemental benefits. For more detailed information regarding external review, please see the External Review Fact Sheet or call (877)850-4740.

External Review Information & Forms

• External Review Request form - Required in all instances.
• Health Care Provider Certification form - use if you are filing for an Expedited or Experimental/Investigational Denial Review; your Physician will have to complete this form
• Appointment of Authorized Representative form - use to provide an appointment to another person for the review
• External Review Appeal to Director form - use to file a final appeal of a decision made pursuant to the Health Carrier External Review
• Fact Sheet
• Approved External Independent Review Organization List
• Provisionally Approved External Independent Review Organization List