What is external review?
External reviewis a second level of appeal after the insurance company's internal process. In Kentucky, you request review through your insurer, which assigns a Department of Insurance–certified independent review entity (IRE) to decide whether the denial was correct.
The program is governed by KRS 304.17A-623 and 806 KAR 17:290. For eligible medical-necessity and experimental/investigational disputes, the IRE decision is generally binding on the insurer.
General overview: Appeals roadmap. Complete Kentucky internal appeals first unless you qualify for expedited or concurrent review.
Who can use Kentucky review?
External review generally applies when:
- You have a Kentucky-regulated health benefit plan
- The plan denied care based on medical necessity, appropriateness, or experimental/investigational treatment
- You completed internal appeal (or qualify for an exception below)
Usually does not apply to:
- Self-funded ERISA employer plans
- Medicaid / KanCare (use MCO appeal and DMS fair hearing)
- Medicare
- Certain limited supplemental policies excluded in KRS 304.17A-614
Deadlines & exhaustion
File with your insurer within 60 days
After internal appeal upholds an adverse determination, you, your authorized representative, or your treating provider (with your written consent) must submit the external review request to the insurer within 60 days of receiving that notice (KRS 304.17A-623(4)).
Include written consent allowing the IRE to obtain medical records from the insurer and providers.
Exceptions
- Emergency medical condition: expedited external review procedures apply (KRS 304.17A-623(11)–(12))
- You may waive a second internal level and proceed to external review after the first level (KRS 304.17A-617)
How to file
- Complete the insurer's internal appeals and keep the final denial letter with external review instructions.
- Submit a written request for external review to the insurer (not directly to the IRE first)—use the address and form in your denial letter.
- Attach your summary, medical records, and the signed medical release the form requires.
- For expedited review, follow insurer instructions; the insurer must forward the case to the IRE within 24 hours.
Questions: Kentucky DOI 800-595-6053 — insurance.ky.gov. Older consumer guide: DOI health appeals guide (PDF).
How long it takes
- Insurer decides whether external review is warranted: often within 5 business days (standard) or 24 hours (expedited) per 806 KAR 17:290
- Standard IRE decision: within 21 calendar days after the IRE receives required information (extensions up to 14 days if you and the insurer agree)
- Expedited IRE decision: within 24 hours after the IRE receives required information (possible 24-hour extension by agreement)
The insurer pays for the IRE review—there is no separate consumer fee for the certified external review process.
Is the decision binding?
For qualifying cases, the IRE's written decision is generally binding on the health insurerregarding whether the denied service was medically necessary or covered under the plan's terms (KRS 304.17A-623).
External review does not change your policy's general benefits—it addresses whether the insurer correctly applied the contract to your specific request.
If the insurer does not comply after a favorable IRE decision, see Regulator complaints and contact DOI.
Medicaid & Medicare
- KanCare (Medicaid): DMS fair hearing (PDF) · kynect benefits
- Medicare: Medicare basics