Appealing a denial is a ladder. You climb the internal appeal first; if that fails, an independent reviewer gets the final, binding word.
| Internal appeal | External review | |
|---|---|---|
| Who decides | The insurer | Independent third party (IRO) |
| When | Required first step | After internal appeal is denied |
| Binding? | No — it's the insurer's own call | Yes — binding on the insurer |
| Cost | Free | Free or nominal (e.g., up to $25 in some states, often refunded) |
| Overturn rate | ~44% | ~50% |
You ask the insurer to reconsider, in writing, with evidence. Federal rules generally require at least one level of internal appeal and a decision within set timeframes (faster for pre-service and urgent cases). This is where most denials are actually overturned — see the full step-by-step.
If the internal appeal fails, you can request an external review by an independent organization with no stake in the outcome. Its decision is binding — if it sides with you, the insurer must cover the care. Depending on your plan, this runs through a state process or the federal (HHS-administered) process; your state page shows which applies to you.
Typically: one (sometimes two) internal levels, then one external review. Urgent situations can be expedited — and in some cases you can request external review at the same time as an urgent internal appeal. Watch your deadlines at every step.
Yes. Self-funded employer plans follow federal ERISA rules; individual, marketplace, and small-group plans usually follow state rules, which can offer stronger protections. CareCost determines which framework applies from your plan details.
Whichever level you're on, we generate the right letter — internal appeal, or an external-review request.
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