What is external review?
External reviewis an independent review of the carrier's adverse determination after internal grievance is complete. The Mississippi Insurance Department (MID) assigns an independent review organization (IRO) to decide whether a denial of medical necessity, appropriateness, setting, level of care, or effectiveness was correct.
The program is governed by MID regulations at 19 Miss. Code. R. Part 3-15 (adopted under the Affordable Care Act). For eligible disputes, the IRO decision is generally binding on the carrier.
General overview: Appeals roadmap. Complete Mississippi internal appeals first unless an exception applies.
Who can use Mississippi review?
External review generally applies when:
- You have a Mississippi-regulated health carrier (fully insured plan)
- The dispute involves medical necessity, appropriateness, health care setting, level of care, effectiveness, or experimental/investigational treatment
- You exhausted internal grievance (or qualify for an exception under Rule 3-15.06)
Usually does not apply to:
- Self-funded ERISA employer plans
- Medicaid / MS CAN (Division of Medicaid fair hearing)
- Medicare
- Limited-benefit products excluded under Rule 3-15.03 (dental-only, vision-only, etc.)
Deadlines & exhaustion
4-month filing window
File a written external review request with MID within four (4) months after receiving the final adverse determination from your insurer (MID external review form, Rule 3-15.07).
Exhaust internal grievance first
- Complete the carrier's internal grievance process (Rule 3-15.06(A))
- 30-day shortcut: no written grievance decision within 30 days → treated as exhausted (Rule 3-15.06(A)(2))
- Retrospective denials: must complete full internal process (Rule 3-15.06(A)(3))
- Carrier may waive exhaustion by agreement (Rule 3-15.06(B)(2))
You may contact MID at 601-359-3569 if you believe you qualify to skip internal review under Rule 3-15.06.
How to file
- Complete internal appeals and keep the final adverse determination letter.
- Gather medical records, the denial letter, and appeal correspondence.
- Complete the MID external review application (PDF).
- Standard review: mail to Office of the Insurance Commissioner, Mississippi Insurance Department, Attn: Life and Health Actuarial Division, P.O. Box 79, Jackson, MS 39205.
- Expedited review: call 601-359-3569 first for submission instructions; include treating-provider certification that standard timing would seriously jeopardize life, health, or maximum function.
Overview: MID — Health Care External Review. Links hub: Mississippi external appeals links.
How long it takes
- Standard review: up to 45 daysfrom MID's receipt of your request (MID form instructions; Rule 3-15.07)
- Expedited review: no more than 72 hours when the treating provider certifies that standard timing would seriously jeopardize life, health, or ability to regain maximum function
- Each party typically has 5 business days to submit information after the IRO is assigned (Rules 3-15.07–3-15.09)
Is the decision binding?
For medical-necessity and similar disputes, the independent reviewer's decision is binding on the health carrierunder Mississippi's ACA-aligned external review rules. You may still pursue other remedies allowed by law if you disagree with the outcome.
Medicaid & Medicare
Medicaid / MS CAN: Use MCO grievance and appeal, then a Division of Medicaid fair hearing—not MID external review. Eligibility disputes: medicaid.ms.gov — eligibility hearings.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS—not Mississippi external review.
More: Medicaid managed care · Medicare appeals.