D.C. External Review

What is external review?

D.C. external reviewprovides independent review when a carrier's final internal appeal upholds a denial based on medical necessity or related grounds (D.C. Code §§ 44-301.07–44-301.10).

The Office of Health Care Ombudsman and Bill of Rights forwards cases to an Independent Review Organization (IRO). The IRO decision is generally binding on the carrier.

Start with D.C. internal appeals. Background: Appeals roadmap.

When you can use it

Eligible disputes often include:

• Medical necessity or appropriateness
• Experimental or investigational treatment
• Continued treatment or stay denials
• Some eligibility and rescission issues

You can generally request external review when:

• You completed internal appeals and received a final denial, or
• The carrier missed required internal or PA deadlines, or
• You qualify for urgent external review (see below)

File within 4 monthsof the insurer's most recent decision (coveragerights.org — D.C.; DHCF — external appeal).

How to request it (step by step)

1. Complete internal appeal unless an urgent-care or deadline exception applies.
2. Read your final denial letter — it must explain external review rights (§ 44-301.06(g)).
3. Gather records: denial letters, clinical notes, treating provider letter, signed medical release.
4. Submit to the Ombudsman within 4 months—include member ID, diagnosis, service requested, and carrier information (coveragerights.org — D.C.).
5. IRO review. The Ombudsman assigns an IRO; you may submit additional documents per Ombudsman instructions.
6. Receive binding decision. If reversed, the carrier must provide coverage.

Mail: Office of Health Care Ombudsman and Bill of Rights, One Judiciary Square, 441 4th Street NW, Suite 900S, Washington, DC 20001. Check current fax numbers on dhcf.dc.gov — Ombudsman.

How long it takes

• Standard review: generally no more than 45 calendar days
• Expedited (urgent/emergency): generally within 72 hours (coveragerights.org — D.C.)

When it does not apply

• Self-funded ERISA plans (unless the employer opts into D.C. external review under § 44-301.11)
• Medicare / Medicare Advantage
• Medicaid / Alliance — MCO grievance then DHCF fair hearing
• Federal government employee plans with separate appeal systems

Urgent cases

For urgent or emergency conditions, you may request expedited external review when you apply for expedited internal review—or skip internal review if the carrier missed deadlines (§ 44-301.03(g)).

Your treating provider should document imminent or serious threat to health. See D.C. prior authorization law and expedited appeals.