What is external review?
External review means an independent reviewer—not your insurance company—reviews certain final coverage denials after internal appeal (or, in urgent cases, without waiting for internal appeal to finish).
Background: Appeals roadmap. Start with Florida internal appeals & grievances.
Florida uses federal external review
Florida does not operate its own state external review program that meets the federal ACA framework. Eligible plans generally use the HHS-administered external review process through an independent review organization contractor (Maximus Federal Services). See coveragerights.org — Florida and HealthCare.gov — external review.
After external review, you can still file a complaint with Florida DFS Consumer Services if the insurer does not comply.
How to request it
After a final internal denial (unless you qualify to skip internal review in an urgent case):
- Call for a request form: (888) 866-6205 or (800) 866-6205 (per Coverage Rights / HealthCare.gov summaries)
- Fax completed forms: (888) 866-6190
- Mail: Maximus Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534
File within 60 calendar daysafter the date on the insurer's final internal appeal notice (coveragerights.org — Florida). Include the denial letter, medical records, and a clinician letter.
Building a strong appeal packet has a checklist.
How long decisions take
- Standard: generally no more than 60 days
- Expedited: often no more than 4 business days after the request is received (coveragerights.org — Florida)
Federal ACA minimum for standard review is often cited as 45 days; Florida consumer guides summarize up to 60 days.
When it does not apply
- Self-funded ERISA employer plans (may have different federal appeal paths)
- Medicare / Medicare Advantage
- Florida Medicaid — MCO grievance and AHCA fair hearing
- Grandfathered plans with limited ACA appeal rights
Urgent cases
If waiting 30–60 days for internal appeal would seriously jeopardize life or ability to regain function, you may request expedited external review without completing standard internal review first (coveragerights.org — Florida). Call (888) 866-6205 for instructions.