What is external review?
External review is an independent review of certain final denials. For most modern health plans, the North Dakota Insurance Department (NCDOI) assigns a certified independent review organization (IRO)to review medical records and decide whether the plan's denial should stand.
The IRO is not your insurance company. For eligible cases, the decision is binding on you and your plan.
General overview: Appeals roadmap. Complete North Dakota internal appeals first unless an urgent exception applies.
Who can use North Dakota review?
External review generally applies when:
- You have an NCDOI-regulated non-grandfathered health plan (most Marketplace and individual plans issued after March 23, 2010)
- The dispute involves medical necessity, appropriateness, level of care, effectiveness, or experimental/investigational treatment
- You exhausted internal appeal (or the insurer waived it)
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Grandfathered plans (pre-March 23, 2010) — may use NCDOI-assigned peer review under different rules
- Medicare and Medicare Advantage (federal Medicare appeals)
- Pure benefit exclusions with no medical judgment component
Deadlines & exhaustion
Four-month filing window
Submit your external review request within four months of the date of the denial unless your insurer allows a longer period (NCDOI). Many consumer guides describe this as about 120 days from the final internal decision—follow your notice.
Exhaust internal appeal first
Complete the insurer's internal grievance/appeal process before external review in most cases. Exceptions include:
- Insurer waives internal appeal
- Expedited external review in urgent situations—you may request expedited internal and external review at the same time when eligible
- Failure to meet internal appeal deadlines may allow proceeding to external review (federal deemed exhaustion rules)
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 external review request to your insurer or directly to NCDOI using the process described at NCDOI — external review.
- If NCDOI accepts your case, you may submit additional information to the IRO within 7 days after acceptance.
Mail: North Dakota Insurance Department, 600 E. Boulevard Ave., Bismarck, ND 58505 · Phone: 800-247-0560
Links hub: North Dakota external appeals links.
How long it takes
- Non-grandfathered plans — standard: IRO decision within 45 days after acceptance
- Non-grandfathered plans — expedited: within 72 hours of receipt for urgent medical decisions
- Grandfathered plans: NCDOI does not mandate a specific completion timeframe—follow your plan and NCDOI guidance
Is the decision binding?
For eligible non-grandfathered disputes, the IRO decision is binding on you and your health plan. If the IRO overturns the denial, the plan must provide coverage or payment consistent with the decision, generally within a few days for standard reviews.
If you disagree with an IRO uphold of denial, limited additional remedies may exist under other state or federal law—ask NCDOI what applies to your case.
Medicaid & Medicare
Medicaid: MCO appeal, then state fair hearingwith HHS/OAH—not commercial IRO review under NCDOI's standard program.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; free help from ND SHIP at 888-575-6611.
More: Medicaid managed care · Medicare appeals.