What is external review?
External review is a second look at certain final denials after internal appeal. For medical disputes on most modern Ohio-regulated plans, the Ohio Department of Insurance (ODI) assigns a certified independent review organization (IRO) that is not your insurance company.
For some pure contractual denials with no medical judgment involved, review may be conducted by the ODI superintendent instead of an IRO.
General overview: Appeals roadmap. Complete Ohio internal appeals first unless an urgent exception applies.
Who can use Ohio review?
External review under Chapter 3922 generally applies when:
- You have an ODI-regulated health plan (most individual and fully insured employer plans)
- The dispute involves medical necessity, appropriateness, level of care, effectiveness, experimental/investigational treatment, or similar medical judgment
- You exhausted internal appeal—or qualify for deemed exhaustion, waiver, or simultaneous expedited review
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare and Medicare Advantage (federal Medicare appeals)
- Medicaid managed care (state fair hearing instead)
IRO vs. superintendent review
Ohio uses two main external review tracks:
- IRO track: medical necessity, medical judgment, or medical information disputes — ODI randomly assigns an accredited IRO (§ 3922.05)
- Superintendent track:denials based purely on contract language with no medical judgment — reviewed by ODI staff; you may have a limited right to return to internal appeal if ODI affirms the plan's explanation
Your final denial notice should identify which track applies. When unsure, call ODI at 800-686-1526.
Deadlines & exhaustion
180-day filing window
Submit your external review request in writing (including electronically) to your health plan issuer within 180 days of the date of the final adverse benefit determination (Chapter 3922). Expedited external review may be requested orally.
Exhaust internal appeal first
Complete internal appeal unless:
- The insurer waives internal appeal
- You qualify for deemed exhaustion (missed deadlines, procedural failures)
- You file simultaneous expedited internal and external review in urgent cases (§ 3922.19)
Additional information to the IRO
After external review is granted, you may submit additional written information within 10 business days of the notice for the IRO or superintendent to consider (§ 3922.05(D)(1)(b)).
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 health plan(the issuer initiates ODI's system and IRO assignment).
- Use ODI model forms if helpful: External Review Request Form.
ODI toolkit: Health coverage & external review process · External Review Program: 614-644-0188 · External.Review@insurance.ohio.gov
Links hub: Ohio external appeals links.
How long it takes
- Standard IRO review: written decision within 45 daysof the issuer's receipt of the request (measured from issuer receipt under § 3922.05(H))
- Expedited IRO review: within 72 hours of issuer receipt for urgent cases
- Experimental/investigational: standard 45-day timeframe also applies to many such reviews under § 3922.10
Is the decision binding?
For eligible IRO medical disputes, the decision is binding on you and your health plan issuer. If the IRO reverses the denial, the plan must provide coverage consistent with the decision.
Superintendent contractual decisions are binding within the scope of Ohio law. If you disagree after external review, limited additional remedies may exist—ask ODI or consult an attorney about your specific case.
Medicaid & Medicare
Medicaid: MCO appeal, then state fair hearing with ODJFS—not commercial IRO review under Chapter 3922.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; free help from OSHIIP at 800-686-1578.
More: Medicaid managed care · Medicare appeals.