What is external review?
External review is an independent document review of certain final denials by a DFR-contracted independent review organization (IRO) that is not your insurance company.
Under ORS 743B.252–743B.256, external review can address medical necessity, experimental or investigational treatment, continuity of care, appropriate setting/level of care, and certain formulary exceptions. The IRO decision is binding on the insurer (ORS 743B.256). There is no cost to you.
General overview: Appeals roadmap. Complete Oregon internal appeals first unless you qualify to bypass.
Who can use Oregon review?
DFR external review generally applies when:
- You have DFR-regulated commercial coverage (many HealthCare.gov and fully insured employer plans)
- The dispute meets external review criteria—medical necessity, experimental/investigational treatment, continuity of care, setting/level of care, or formulary exception—not pure contractual exclusions or premium disputes
- You exhausted internal appeals—or are deemed exhausted, mutually agree to skip internal review, or qualify for expedited simultaneous review
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare, Medicaid (OHP), and other federal plans
- Services that are not covered benefits under your policy
DFR randomly assigns a contracted IRO after your insurer forwards your request (DFR — denied claims). Only the IRO decides if a case qualifies for full review.
Deadlines & exhaustion
180 calendar days
Submit a written request for external review within 180 calendar days after your final adverse benefit determination letter (ORS 743B.255). Missing this deadline generally disqualifies the case.
Exhaust internal appeals first
Complete the insurer's internal grievance unless you and the insurer agree to proceed directly to external review, you are deemed to have exhausted internal appeals under ORS 743B.250, or you qualify for expedited external review (DFR — external review regulation).
Additional information to the IRO
After DFR assigns an IRO, you may submit additional documents directly to the IRO. DFR recommends gathering records before filing; you typically have about 7 days after the assignment letter to send materials to the IRO.
How to file
- Complete internal appeal and obtain a final adverse benefit determination with external review rights when required.
- Submit a written external review request to your insurer using the form in your final denial packet (the insurer must forward it to DFR).
- For expedited review, include a provider letter stating that the ordinary external review timeline would jeopardize life, health, or ability to regain maximum function, plus supporting documentation.
- When DFR assigns an IRO, submit any additional records directly to the IRO and notify them if more documents are coming.
- Report IRO procedural noncompliance to DFR within 7 business days of the written decision if applicable ( email: exreview.ins@dcbs.oregon.gov).
Links hub: Oregon external appeals links.
How long it takes
- Standard external review: completed within 30 calendar days (DFR consumer guidance; aligns with ORS 743B.256 timelines)
- Expedited external review: completed within 3 calendar days when clinically appropriate (DFR consumer page); provider certification required
- Expedited review may be available when you request external review before exhausting internal appeals in qualifying urgent situations (ORS 743B.252)
- The IRO may issue an ineligibility letter if the case does not qualify for full review
Is the decision binding?
For qualifying external reviews, the IRO decision is binding on the insurer. If the IRO overturns the denial, the insurer must provide coverage. If upheld, you may seek legal advice; DFR cannot provide legal counsel.
If the insurer fails to comply with an IRO decision, you may have a private right of action under ORS 743B.258.
Medicaid & Medicare
Oregon Health Plan: Exhaust CCO appeal, then request an OHA hearing within 120 days of the Notice of Appeal Resolution (OHP appeals & hearings)—not DFR commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; Oregon SHIP help via Oregon SHIP.
More: Medicaid managed care · Medicare appeals.