What is external review?
External review is an independent review of certain final denials. Under NRS 695G.241 to 695G.310, the Office for Consumer Health Assistance (OCHA) receives your request and assigns a Division of Insurance–approved independent review organization (IRO).
You submit the external review request to OCHA, not directly to the IRO. The carrier pays the cost of the review (NRS 695G.297).
General overview: Appeals roadmap. Complete Nevada internal appeals first unless an urgent exception applies.
Who can use Nevada review?
External review generally applies when:
- You have a Nevada-regulated fully insured health plan (including most Nevada Health Link plans)
- The dispute involves medical necessity, appropriateness, experimental/investigational treatment, or similar clinical judgments
- OCHA determines the request is eligible
Usually does not apply to:
- Self-funded ERISA employer plans
- Nevada Medicaid (DHCFP fair hearing)
- Medicare
Deadlines & exhaustion
Four-month filing window
File a written request with OCHA within four months after you receive notice of the adverse determination (NRS 695G.251(1)). Always follow any deadline in your denial letter.
Exhaust internal appeal first
Complete the carrier's internal grievance process before external review in most cases. Exceptions include:
- No written grievance decision within 30 days after filing (without agreed delay) — treated as exhausted (NRS 695G.245(1)(b))
- Expedited external review filed with simultaneous expedited grievance when urgent harm is at risk (NRS 695G.245, 695G.271)
- Certain experimental/investigational denials with physician certification (NRS 695G.275)
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, policy, and medical records.
- Complete OCHA's external review request form—your carrier should include it with the final denial.
- Mail to: Office for Consumer Health Assistance, 555 E. Washington Ave., Suite 4800, Las Vegas, NV 89101, or contact OCHA for current submission options.
- For expedited review, call 702-486-3587 or 888-333-1597 and include physician certification.
Links hub: Nevada external appeals links.
How long it takes
- Standard review: IRO must approve, modify, or reverse the denial within 15 days after receiving required information (NRS 695G.253(2))
- Expedited review: OCHA approves or denies expedited eligibility within 72 hours; the IRO then decides on an expedited schedule (NRS 695G.271, 695G.275)
- OCHA assigns the IRO after eligibility screening (NRS 695G.251)
Is the decision binding?
For eligible clinical disputes on fully insured plans, the IRO decision is binding on the health carrier. If the IRO reverses the denial, the carrier must provide coverage consistent with the decision. OCHA cannot overturn an IRO determination, though you may still file a complaint with the Division of Insurance about other conduct.
Medicaid & Medicare
Nevada Medicaid: MCO appeal, then DHCFP state fair hearing—not commercial external review under NRS 695G.241–695G.310.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.