Arkansas External Review

What is external review?

External review means an independent review organization (IRO)—licensed and assigned through the Arkansas Insurance Department—decides whether the plan's denial was correct.

For many fully insured Arkansas plans, the IRO's decision on medical necessity is binding on the insurer (the plan still cannot be forced to cover something your policy excludes).

External review is usually notthe first step. Finish the plan's internal appeals first, unless the law lets you skip ahead because of urgency or missed deadlines. Start with Arkansas internal appeals & grievances.

Background: Appeals roadmap.

When you can use it

External review commonly covers disputes about:

• Medical necessity
• Appropriateness, setting, or level of care
• Experimental or investigational treatment
• Some coverage disputes after internal review is complete

It is usually not the right tool for simple billing errors or missing paperwork—see Denial decoder.

You can generally request external review when:

• You completed all required internal appeal levels and got a final adverse determination, or
• The plan did not send a written internal decision within 30 days (pre-service) or 60 days (post-service) after you filed (Rule 76, Section 7), or
• You qualify for expedited external review (see below)

How to request it (step by step)

1. Read your final denial letter. It should mention external review and the Arkansas Insurance Department.
2. Gather documents: denial letters, medical records, and a treating clinician letter explaining why care is needed.
3. Contact the External Review Division for forms and filing instructions — 1-800-852-5494 or 1-800-282-9134 (consumer line; ask for External Review) — or start at insurance.arkansas.gov — External Review.
4. File a written request with the Insurance Commissioner within four months of the final adverse determination (Rule 76, Section 8). Mail is commonly used:
   External Review Division, Arkansas Insurance Department, 1200 West Third Street, Little Rock, AR 72201.
5. The Department assigns an IRO to review the medical issues. The insurer sends records to the IRO.
6. You receive the IRO decision. If the IRO overturns the denial, the plan must generally provide the coverage (Rule 76).

A sample request form (same filing address and four-month rule) is published by QualChoice (External Review Request Form (PDF)). There is typically no cost to the member for state external review.

Full regulation: Rule 76 (PDF).

How long it takes

• Standard external review: often up to 45 days from when the Department receives your request (consumer materials and Rule 76 timelines)
• Expedited external review: the IRO must decide within 72 hours in qualifying urgent cases (Rule 76, Section 9)

Complex cases (especially experimental treatment) can involve additional clinical reviewer steps and take longer.

When it does not apply

• Self-funded ERISA employer plans — federal process or plan appeals only
• Medicare / Medicare Advantage — CMS appeals
• Medicaid / ARHOME — DHS fair hearing (file an appeal with DHS)
• Services your policy never covers (plan exclusions)

After external review, if you believe the insurer broke the law, you can file a complaint — Regulator complaints.

Urgent cases

Ask for expedited review when your treating provider certifies that waiting for a standard timeline would seriously jeopardize life, health, or ability to regain maximum function—or in certain inpatient/emergency situations described in Rule 76.

You may be able to request expedited external review at the same time as an expedited internal appeal; the assigned IRO decides whether you must finish internal review first (Rule 76, Section 7(B)).

For urgent prior authorization denials, also see Arkansas prior authorization law and expedited appeals on the Appeals Roadmap.