What is external review?
External review means an independent reviewer—not your insurance company—reviews certain final coverage denials after internal appeal (or in some urgent cases, without waiting for internal appeal to finish).
For a general explanation of when external review helps and what to send, see Appeals roadmap. This guide covers how Alabama residents access external review—not a separate Alabama Department of Insurance IRO program like some states have.
Start with the plan's internal process: Alabama internal appeals & grievances.
Alabama uses federal external review
Alabama does not maintain a state external review process that meets the federal consumer protection framework on its own. Issuers and plans in Alabama generally participate in the HHS-administered external review process operated through an independent review organization contractor (historically associated with Maximus Federal Services). The U.S. Department of Labor lists Alabama among states using the federal process (dol.gov — Technical Release 11-02).
Consumer guides summarize the same path: call for a request form, then submit to the federal administrator (coveragerights.org — Alabama; HealthCare.gov — external review).
How to request it
After you receive a final adverse determination from the internal appeal (unless you qualify to skip internal review in an urgent case), request external review in writing through the federal process:
- Call for a request form: 585-348-3300 (per Coverage Rights and HealthCare.gov summaries)
- Fax completed forms: (888) 866-6190
- Mail: Maximus Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534
You generally must file within 60 calendar daysafter the date on the insurer's final internal appeal notice (coveragerights.org — Alabama). Keep proof of mailing or fax transmission.
Practical tip:Include the internal appeal denial, medical records, and a clinician letter explaining why the service meets medical necessity under the plan's criteria. See Building a strong appeal packet.
How long decisions take
- Standard external review: generally no more than 60 days (coveragerights.org — Alabama)
- Expedited external review: generally no more than four business days after the request is received when the case is urgent (coveragerights.org — Alabama)
For federally regulated plans, the external decision is generally binding on the health insurance issuer for the coverage decision at issue, subject to federal exceptions explained on HealthCare.gov — external review.
When it does not apply
- Medicare and many Medicaid disputes: use Medicare or Medicaid appeal systems instead of the federal commercial external review process.
- Self-funded ERISA plans: may follow federal external review for non-grandfathered plans or other DOL processes; confirm in the denial notice and SPD. See Self-funded ERISA plans.
- Purely administrative denials (eligibility, timely filing, coding without medical necessity) may need corrected claims or internal fixes rather than medical external review—see Denial decoder.
After external review, if coverage is still denied, you may file a complaint with ALDOI — Regulator complaints and aldoi.gov — file a complaint.
Urgent cases
Federal rules may allow you to request expedited external review—or to seek external review without completing a full internal appeal first—when waiting 30 to 60 days would seriously jeopardize life, health, or ability to regain function (HealthCare.gov — internal appeals (urgent situations)).
Ask the treating clinician to document urgency the same day. For expedited federal external review, decisions are generally due within four business days after the request is received (coveragerights.org — Alabama).
More on urgent timelines across plan types: expedited appeals on the Appeals Roadmap.