What is external review?
External reviewis a second level of appeal after the insurance company's internal process. In Louisiana, you request review through your health insurance issuer, which notifies the Louisiana Department of Insurance (LDI) to assign a certified independent review organization (IRO).
The program is governed by RS 22:2433 through 22:2441 and LDI regulations (RS 22:2436, La. Admin. Code tit. 37, § XIII-6209). For eligible cases, the IRO decision is generally binding on the issuer.
General overview: Appeals roadmap. Complete Louisiana internal appeals first unless an exception applies.
Who can use Louisiana review?
External review generally applies when:
- You have a Louisiana-regulated health benefit plan
- The denial involves medical necessity, appropriateness, or experimental/investigational treatment
- You exhausted internal appeal (or qualify for an exception under RS 22:2435)
Usually does not apply to:
- Self-funded ERISA employer plans
- Medicaid / Healthy Louisiana (MCO appeal and state fair hearing)
- Medicare
Deadlines & exhaustion
Four-month filing window
File a request for external review with your health insurance issuer within 4 months after you receive an adverse determination or final adverse determination (RS 22:2436(A)).
Exhaust internal appeals first
You must usually complete the issuer's internal claims and appeals process (RS 22:2435), unless:
- No written internal decision within 30 days of filing a grievance (RS 22:2433)
- You qualify for expedited external review without full internal review
- Another exception in RS 22:2435 applies
How to file
- Complete internal appeals and keep the final adverse determination letter with external review instructions.
- Submit a written external review request to your issuer within 4 months, with any forms and medical records the letter requires.
- Within 5 business days, the issuer performs a preliminary review and notifies you whether the request is accepted (RS 22:2436(B)–(C)).
- If eligible, the issuer submits the case to LDIfor IRO assignment through LDI's industry portal; you should receive IRO contact information within about 1 business day.
- You may send additional information to the IRO within 5 business daysof LDI's notice (IRO may accept later materials at its discretion).
Questions: LDI Office of Health Insurance 225-342-1355 or ConsumerAppeals@ldi.la.gov — ldi.la.gov — health insurance.
How long it takes
- Issuer preliminary review: within 5 business days of receiving your request
- LDI eligibility determination (if disputed): often within 5 business days
- Standard IRO decision: within 45 days after the IRO receives the case (RS 22:2436(I)); extensions up to 14 days if you and the issuer agree
- Expedited IRO decision: within 72 hours after the issuer receives the request (RS 22:2437); possible 24-hour extension by agreement
The issuer pays for the IRO review—there is no separate consumer fee for the certified external review process.
Is the decision binding?
For qualifying medical-necessity and experimental/investigational disputes, the IRO's written decision is generally binding on the health insurance issuer. The IRO must explain the basis for upholding or reversing the adverse determination.
Experimental/investigational denials may follow additional procedures under RS 22:2438.
If the issuer does not comply after a favorable IRO decision, see Regulator complaints and contact LDI.
Medicaid & Medicare
- Healthy Louisiana: LDH — Medicaid appeals · Division of Administrative Law
- Medicare: Medicare basics