What is external review?
Georgia external review and the Patient's Right to Independent Review Actprovide independent review when a carrier's final decision denies care based on medical necessity or related grounds (O.C.G.A. §§ 33-20A-30–33-20A-42).
OCI assigns an independent review organization (IRO). Decisions are generally binding on the carrier for eligible cases.
Start with Georgia internal appeals. Background: Appeals roadmap.
When you can use it
Eligible disputes often include:
- Medical necessity
- Experimental or investigational treatment (with specific criteria under § 33-20A-32)
- Continued stay or course of treatment
You can generally request review when:
- You completed internal appeals or managed care grievances and received a final denial, or
- You qualify for expedited external review in urgent cases
Submit a written request to the Georgia Department of Insurance using OCI forms included with your denial (§ 33-20A-35). ACA plans may also reference a 120-day federal filing window—follow your letter.
How to request it (step by step)
- Finish internal appeal / grievance unless urgent exceptions apply.
- Read your final denial — it must explain independent review in bold, large type (§ 33-20A-35(a)).
- Complete OCI forms from the notice or oci.georgia.gov.
- Submit to OCI with medical records and clinician support (coveragerights.org — Georgia).
- OCI assigns an IRO on a rotating basis and notifies you (§ 33-20A-35(c)).
- Receive binding decision.
Complaints after review: oci.georgia.gov — file a complaint.
How long it takes
- Standard external review: generally no more than 30 days (coveragerights.org — Georgia; § 33-20A-37)
- Expedited: generally within 72 hours after the reviewer receives the request
The carrier generally pays the cost of standard independent review for eligible enrollees.
When it does not apply
- Self-funded ERISA employer plans
- Medicare / Medicare Advantage
- Georgia Medicaid — CMO grievance and DCH fair hearing
- Pure plan exclusions with no medical-necessity dispute
Urgent cases
Request expedited external review when standard timelines would seriously jeopardize life, health, or ability to regain function (§ 33-20A-37). You may be able to request expedited internal and external review together per federal and state materials.