What is external review?
External review is an independent review of the carrier's adverse determination. The Missouri Department of Commerce and Insurance (DCI) contracts with an Independent Review Organization (IRO) to decide whether a denial involving medical necessity, appropriateness, setting, level of care, effectiveness, or experimental/investigational treatment was correct.
DCI's Division of Consumer Affairs screens requests, determines eligibility, and forwards eligible cases to the IRO. The service is free to consumers for state-administered external review.
General overview: Appeals roadmap. See also Missouri internal appeals.
Who can use Missouri review?
External review generally applies when:
- You have a Missouri-regulated fully insured health plan
- The dispute involves a medical judgment (medical necessity, appropriateness, experimental treatment, etc.) or a rescission of coverage
- DCI determines the request is eligible for external review
Usually does not apply to:
- Self-funded ERISA employer plans
- MO HealthNet / Medicaid (state fair hearing through the Division of Medicaid)
- Medicare
- Limited-benefit products (dental-only, vision-only, etc.) excluded from utilization review rules
Deadlines & exhaustion
4-month filing window (federal standard)
For Marketplace and other ACA-compliant plans, file a written external review request within four (4) months after the date you receive a notice of adverse determination or final adverse determination (HealthCare.gov — external review). Always follow any shorter deadline in your denial letter.
Internal appeals: suggested, not required
DCI suggests completing all carrier appeal levels first but states that doing so is not a requirement before external review (DCI — external review). Completing internal appeals is still usually the fastest path and builds a stronger record.
If the carrier is late on internal appeal
Under federal rules, if you do not receive a timely internal appeal decision (often 30 days preservice / 60 days post-service), you may be treated as having exhausted internal review and may file for external review.
How to file
- Gather the denial letter, appeal correspondence, and medical records.
- Contact DCI's Insurance Consumer Hotline at 800-726-7390 or file through insurance.mo.gov.
- DCI reviews eligibility and may contact the carrier for your claims file.
- If eligible, DCI forwards the case to the IRO; you may have about 15 business days to submit additional medical information once the case is assigned.
Consumer overview: DCI — health insurance denials and external review. Links hub: Missouri external appeals links.
How long it takes
- Standard review: no more than 45 calendar days from when the IRO receives all information to notify you of the outcome (DCI consumer materials)
- IRO often issues a decision to DCI within about 20 calendar days after receiving complete information
- Expedited review: no more than 72 hours when urgent harm is at risk (federal standard)
Is the decision binding?
For eligible medical-necessity disputes, the IRO decision is binding on the health carrierunder Missouri's ACA-aligned external review program. The carrier must comply if the denial is overturned.
Medicaid & Medicare
MO HealthNet: Use MCO appeal, then a state fair hearing with the Division of Medicaid—not DCI external review. See MO HealthNet — appeals and grievances.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS—not Missouri DCI external review.
More: Medicaid managed care · Medicare appeals.