What is external review?
External reviewis a second level of appeal after the insurance company's internal process. In Illinois, the Department of Insurance assigns an independent review organization (IRO)—a neutral medical reviewer that does not work for the health carrier.
The program is governed by the Health Carrier External Review Act (215 ILCS 180). For eligible denials involving medical necessity, appropriateness, setting, level of care, or effectiveness, the IRO's decision is generally binding on the carrier.
General overview: Appeals roadmap.
Who can use IDOI review?
External review through IDOI generally applies to:
- Health carriers regulated under Illinois insurance law (many fully insured individual, small group, and large group plans)
- Denials classified as adverse determinations or final adverse determinations on clinical grounds
Usually does not apply to:
- Self-funded ERISA employer plans (unless the plan voluntarily participates)
- Medicaid (use MCO appeal and HFS fair hearing instead)
- Medicare (use Medicare appeals and, for Advantage, CMS / IRE processes)
- Purely contractual exclusions with no medical-necessity dispute
Deadlines & exhaustion
Exhaust internal appeals first
You must usually complete the carrier's internal appeal process before IDOI will accept external review (215 ILCS 180/30). Exceptions may apply when:
- The carrier agrees to waive exhaustion
- You meet statutory criteria for going straight to external review (see statute and IDOI forms)
Four-month filing window
Request external review within 4 months after you receive notice of the final adverse determination (IDOI — File an external review).
Internal appeal steps: Illinois internal appeals.
How to file with IDOI
- Download the request form from IDOI — File an external review.
- Attach the final denial letter and key medical records.
- Submit to the Office of Consumer Health Insurance, Illinois Department of Insurance, 320 W. Washington Street, Springfield, IL 62767 (check the form for current fax and email).
- Email (as listed by IDOI): externalreview@illinois.gov
There is no fee charged to consumers for state external review; the health carrier pays the IRO (215 ILCS 180/70).
How long it takes
- Standard review: often within about 45 days of a complete request
- Expedited review: often within 72 hourswhen the patient's health would be seriously jeopardized by waiting
For urgent cases, you may be able to request concurrent internal and external review in some situations—confirm current IDOI instructions on the filing page.
Is the decision binding?
For covered clinical disputes, the IRO decision is generally binding on the health carrier. The plan must cover the service as ordered if the IRO overturns the denial (subject to normal cost-sharing and network rules).
Carriers must describe external review rights in plan materials and point to IDOI contact information (215 ILCS 180/75).
If you believe the carrier is not complying after a favorable IRO decision, see Regulator complaints and contact IDOI.
Medicaid & Medicare
- Medicaid: HFS appeals and fair hearings
- Medicare: Medicare basics