What is external review?
External review is an independent review of certain final denials. Under RSA 420-J:5-a through 420-J:5-e, the New Hampshire Insurance Department receives your request and assigns a certified independent review organization (IRO).
The IRO is not affiliated with your insurance company. The carrier pays the cost of the review in most cases (RSA 420-J:5-e, I).
General overview: Appeals roadmap. Complete New Hampshire internal appeals first unless an urgent exception applies.
Who can use New Hampshire review?
External review generally applies when:
- You have a fully insured New Hampshire health or dental plan
- The dispute involves medical necessity, appropriateness, health care setting, level of care, effectiveness, or experimental/investigational treatment
- The Insurance Department accepts your request after preliminary review
Usually does not apply to:
- Self-funded ERISA employer plans
- Medicaid, CHIP, and Medicare (RSA 420-J:5-a, II)
- Provider malpractice or professional negligence claims (RSA 420-J:5-a, III)
Deadlines & exhaustion
180-day filing window
Submit a written external review request to the Insurance Commissioner within 180 daysof the carrier's final denial (RSA 420-J:5-a, I(c)). 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:
- Carrier agrees to skip internal review (RSA 420-J:5-a, I(b))
- No timely internal decision after you filed standard or expedited appeal (RSA 420-J:5-a, I(b))
- Expedited external review may run at the same time as expedited internal appeal when urgent (RSA 420-J:5-c, II)
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, policy, and medical records.
- Submit a written request to the NH Insurance Department using its external review process and forms (NHID — independent external review).
- For expedited review, include physician certification that standard time frames would jeopardize life, health, or maximum function.
Links hub: New Hampshire external appeals links.
How long it takes
- Preliminary review: Department completes eligibility review within 7 business days of receipt (RSA 420-J:5-b, I)
- Standard review: IRO decision within 15 days after receiving required information (RSA 420-J:5-b; NHID notes reviews may take up to 60 days in complex cases)
- Expedited review: Department acts within 72 hours on expedited eligibility; IRO decides on an expedited schedule (RSA 420-J:5-c; NHID)
Is the decision binding?
For eligible disputes, the IRO decision is binding on the health carrier and enforceable by the Commissioner (RSA 420-J:5-e, II). If the IRO reverses the denial, the carrier must provide coverage consistent with the decision.
Medicaid & Medicare
New Hampshire Medicaid: MCO appeal, then DHHS fair hearing—not commercial external review under RSA 420-J:5-a.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.