What is external review?
External reviewmeans an independent review organization—not your insurance company—reviews certain final denials after you have gone through the plan's internal appeal process.
For advocates, think of it as a second opinion from outside the plan. If you win, the external decision is generally binding on the insurer for fully insured Indiana plans that follow these rules.
External review is not the first step. Start with the plan's internal grievance and appeal process. See Indiana internal appeals & grievances.
When Indiana external review applies
After the internal appeal, Indiana external review may be available for certain adverse determinations involving appropriateness, medical necessity, experimental or investigational treatment, and certain rescissions. Indiana Code § 27-8-29-12 describes when a covered person may request external review for insurers.
Indiana HMOs have a similar external grievance process for adverse utilization review determinations, medical necessity denials, experimental or investigational denials, and certain rescissions. See Indiana Code § 27-13-10.1-1.
External review is not for every problem. If the issue is only a coding error, missing information, timely filing dispute, or eligibility correction, the better path may be a corrected claim, provider billing help, or an internal administrative fix—not external review.
How to request it
The request is generally made in writing to the insurer after the internal appeal process ends. Indiana law says the request must usually be filed no more than 120 calendar daysafter you are notified of the insurer's appeal resolution. Indiana Code § 27-8-29-12
Indiana external review uses an independent review organization (IRO) selected from certified review organizations. The IRO must avoid material conflicts of interest. The member does not pay the IRO's costs—the insurer pays. Indiana Code § 27-8-29-13
Practical tip:keep proof of when you mailed or submitted the external review request, and save the insurer's internal appeal denial letter—it usually starts the 120-day clock.
How long decisions take
- Standard external review: the IRO must generally decide within 15 business days after the external grievance is filed. Indiana Code § 27-8-29-15
- Expedited external review: generally within 72 hourswhen the standard timeline would seriously jeopardize the patient's life, health, or ability to regain maximum function. Indiana Code § 27-8-29-13
The external review decision is binding on the insurer for plans subject to these Indiana rules.
HMO external review requests also generally must be filed within 120 days. Expedited review may be available when delay could seriously jeopardize life, health, or maximum function. Indiana Code § 27-13-10.1-1
When it does not apply
- Medicare: if Medicare provides an external review process for the same grievance, the person may not request Indiana external review for that same grievance. Indiana Code § 27-8-29-23
- Self-funded employer plans: Indiana external review rules often do not apply. The plan may follow federal ERISA appeals instead. See Self-funded ERISA plans. The Indiana Department of Insurance notes that many self-funded employer plans are regulated under federal law; consumers may need the U.S. Department of Labor's Employee Benefits Security Administration (dol.gov — EBSA). IDOI — resolving health care insurance disputes
Not sure which rules apply? Start with Indiana: Start Here to confirm plan type and regulator.
Urgent cases
If waiting for the normal appeal process could seriously harm the patient's health, ask for an expedited appeal right away—internal and external.
Ask the treating doctor to document urgency in writing. The letter should explain why a standard timeline could seriously jeopardize life, health, ability to regain maximum function, or ability to avoid severe pain.
For Indiana external review, expedited decisions are generally due within 72 hours after the external grievance is filed when delay would seriously jeopardize life, health, or maximum function. Indiana Code § 27-8-29-13
For Marketplace plans subject to federal ACA appeal rules, urgent cases may sometimes allow internal appeal and external review at the same time. HealthCare.gov — internal appeals explains that in urgent health situations, a person may ask for external review while the internal appeal is still pending.
More on urgent timelines across plan types: expedited appeals on the Appeals Roadmap.