What is external review?
External review is an independent review of certain final denials. After internal appeal, your health plan must arrange review by an independent review organization (IRO) approved by the Rhode Island Health Insurance Commissioner.
The IRO is not your insurance company. For eligible cases, the decision is binding on you and your plan.
General overview: Appeals roadmap. Complete Rhode Island internal appeals first unless an urgent exception applies.
Who can use Rhode Island review?
External review under § 27-18.9-8 generally applies when:
- You have OHIC-regulated commercial coverage (most HealthSource RI and fully insured employer plans)
- The dispute involves a non-administrative adverse benefit determination (medical necessity, level of care, experimental/investigational treatment, etc.)
- You exhausted the final internal appeal level
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 (EOHHS fair hearing instead)
- Pure administrative denials handled under separate complaint procedures
Deadlines & exhaustion
Four-month filing window
You have at least four months after receipt of the decision on your final internal appeal to request external review (§ 27-18.9-8(a)(3)). Follow the deadline in your denial notice.
Exhaust internal appeal first
Complete all required internal appeal levels before external review in most cases. Ask RIREACH (855-747-3224) if you are unsure whether internal review is complete.
Additional information to the IRO
You must receive notice that you have at least 5 business days from the external appeal notice to submit additional information to the IRO (§ 27-18.9-8(b)(1)).
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, and medical records.
- Submit a written external review request to your health insurer or review agent following the instructions in your final denial notice.
- The plan must forward your case to an OHIC-approved IRO within 5 business days and notify you how to submit additional records.
OHIC consumer help: ohic.ri.gov/consumer-protection · RIREACH: 855-747-3224
Links hub: Rhode Island external appeals links.
How long it takes
- Standard review: IRO decision within 45 calendar days of the request, and no later than 10 calendar days after receiving all information needed to complete review
- Expedited review (urgent/emergent): as fast as possible, not more than 72 hours after the IRO receives the request; oral notice allowed, followed by written decision within 48 hours
- Non-formulary drug appeals: 72 hours standard or 24 hours if expedited
Is the decision binding?
For eligible disputes, the IRO decision is binding on you and your health plan. If the IRO overturns the denial, the plan must provide coverage consistent with the decision.
If you disagree after an uphold, limited additional remedies may exist—ask RIREACH or OHIC what applies to your case.
Medicaid & Medicare
Medicaid: MCO appeal, then state fair hearing with EOHHS—not commercial IRO review under Chapter 27-18.9.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.