What is external review?
External review means an accredited independent review organization (IRO)—not your insurer—reviews certain coverage denials after internal review (or sooner if the insurer missed regulatory deadlines).
Alaska operates its own external healthcare review program through the Division of Insurance. That is different from Alabama, which uses the federal HHS-administered process for many plans. For general concepts, see Appeals roadmap.
Start with internal review: Alaska internal appeals & grievances.
When Alaska external review applies
External review is available for many fully insured Alaska health and dental plans when a service or treatment is denied based on medical necessity, appropriateness, health care setting, level of care, treatment effectiveness, or because care is considered experimental or investigational (Division of Insurance — external review instruction guide).
Generally you must receive a final adverse determination after internal grievance review first. You may skip internal review if:
- The insurer failed to meet internal review regulatory requirements (including timelines), or
- The insurer waives the exhaustion requirement
(Division of Insurance — consumer FAQ)
Purely contractual or administrative disputes (for example some billing-only issues) may not qualify for external review even if they are grievances.
How to request it
Submit an application to the Division of Insurance Consumer Services. Read the guide first to avoid delays: Guide to External Review (PDF).
- Patient or legal guardian: use the External Review Application Form (linked from commerce.alaska.gov — External Healthcare Review)
- Provider or other representative: use the Third-Party External Review Application Form
- Submit by email (preferred): consumerservices@alaska.gov
- Fax: (907) 269-7910
- Phone for questions or large files: (907) 269-7900 (ask for Consumer Services)
Include the final adverse determination, policy terms cited, medical records, and clinician support. There is no charge to the member—the insurer pays IRO costs (Division FAQ).
Filing deadline: generally within 180 days of the final adverse determination (extensions possible for extenuating circumstances). You also generally have up to 180 days from an initial adverse determination to file an internal grievance (Division FAQ).
The Division performs a preliminary eligibility review, then assigns an IRO by rotation from approved organizations (3 AAC 28.958).
How long decisions take
- Standard external review: IRO decision generally within 45 days after the request (3 AAC 28.958(p); Division FAQ)
- Expedited external review: generally within 72 hours when delay would seriously harm the patient (external review instruction guide). A physician may complete a Provider Certification Form for expedited or experimental/investigational cases.
If the IRO reverses the insurer, the insurer must immediately comply and provide coverage (Division FAQ).
When it does not apply
- Self-funded ERISA plans: Division external review generally does not apply; use ERISA appeals and federal external review if available. See Self-funded ERISA plans.
- Medicare and Medicaid: use program-specific appeal systems.
- Non-medical grievances: some contractual complaints may not be eligible for external review even if they can be grieved internally.
Final notices should list rights to external review, contact the Division, or pursue superior court action (Division FAQ).
Urgent cases
Request expedited internal grievance review first (3 AAC 28.938—72-hour decision). For external review, use the expedited application path and Provider Certification Form when appropriate (commerce.alaska.gov — External Healthcare Review).
If the insurer missed internal review deadlines, you may be able to go straight to external review—document dates and contact Consumer Services.
Cross-plan urgent guidance: expedited appeals on the Appeals Roadmap.