What is external review?
External review is an independent review of certain final denials. After internal appeal, your health carrier assigns an independent review organization (IRO) approved by the South Carolina Department of Insurance.
The IRO is not your insurance company. For eligible cases, the decision is binding on you and your plan.
General overview: Appeals roadmap. Complete South Carolina internal appeals first unless an urgent exception applies.
Who can use South Carolina review?
External review under Article 19 of Chapter 38-71 generally applies when:
- You have SCDOI-regulated commercial coverage (most HealthCare.gov and fully insured employer plans)
- The dispute involves medical necessity, appropriateness, level of care, effectiveness, or experimental/investigational treatment
- The amount in dispute is at least $500 for covered benefits (§ 38-71-1950(B))
- You exhausted internal appeal—or qualify for deemed exhaustion or waiver
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 (SCDHHS fair hearing instead)
- Retrospective review denials unless you exhausted internal appeal and may be held financially responsible (§ 38-71-1950(C))
Stage IV metastatic cancer imaging denials may qualify for expedited external review under § 38-71-144.
Deadlines & exhaustion
60-day filing window
Submit a written external review request to your health carrier within 60 days after you receive notice of an adverse determination or final adverse determination (§ 38-71-1950(A)). This is shorter than the federal four-month maximum—do not wait.
Expedited external review (§ 38-71-1980)
You may file within 15 days of the notice when your treating physician certifies a serious medical condition, or when you are in an ongoing hospital stay and receive a final adverse determination for continued care.
Exhaust internal appeal first
Complete internal appeal unless deemed exhaustion, waiver, or qualifying expedited parallel review applies (§ 38-71-1960).
Additional information to the IRO
You have at least 7 business days after the external appeal notice to submit additional information to the IRO (§ 38-71-1970).
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, HIPAA authorization, and medical records.
- Submit a written external review request to your health carrier per your denial notice.
- Within 5 business days, the carrier must assign an SCDOI-approved IRO and forward your file.
SCDOI IRO program: External review — independent review organizations · Consumer help: 800-768-3467
Links hub: South Carolina external appeals links.
How long it takes
- Standard review: IRO decision within 45 daysof the carrier's receipt of the request, and no later than 10 calendar days after receiving all information needed to complete review
- Expedited review: 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
- Carrier assigns IRO within 5 business days of receiving your request
Is the decision binding?
For eligible disputes, the IRO decision is binding on you and your health carrier. If the IRO overturns the denial, the plan must provide coverage consistent with the decision.
Medicaid & Medicare
Medicaid: MCO appeal, then state fair hearing with SCDHHS—not commercial IRO review under Chapter 38-71.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.