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 TDCI to review medical disputes.
The IRO is not your insurance company. For eligible cases, the decision is binding on you and your plan.
General overview: Appeals roadmap. Complete Tennessee internal appeals first unless an urgent exception applies.
Who can use Tennessee review?
External review under Ch. 56-61 generally applies when:
- You have TDCI-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
- You exhausted internal appeal—or qualify for deemed exhaustion or waiver (§ 56-61-115)
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare and Medicare Advantage (federal Medicare appeals)
- TennCare / CoverKids medical appeals (state fair hearing through TennCare—not Ch. 56-61 IRO review)
- TennCare provider claim disputes with MCOs (separate independent review under § 56-32-126 for providers—not member benefit appeals)
Deadlines & exhaustion
Six-month filing window
Submit a written external review request to your health carrier within six months after you receive notice of an adverse determination or final adverse determination (§ 56-61-114). Federal law also sets a minimum four-monthwindow—Tennessee's six-month period is longer, but do not wait.
Expedited external review (§ 56-61-117)
Request expedited review when standard timing would seriously jeopardize life, health, or ability to regain maximum function. You may request expedited external review at the same time as a first-level internal appeal in qualifying urgent cases. The IRO must decide within 72 hours of receiving a complete request.
Exhaust internal appeal first
Complete internal appeal unless deemed exhaustion, waiver, or qualifying simultaneous expedited review applies (§ 56-61-115).
Additional information to the IRO
After the carrier assigns an IRO, follow the instructions in your assignment notice to submit supplemental records (§ 56-61-116).
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 and Ch. 56-61-113.
- The carrier assigns a TDCI-approved IRO and forwards your file; you receive notice with instructions for supplemental submissions.
TDCI consumer help: 800-342-4029 · Consumer resources
Links hub: Tennessee external appeals links.
How long it takes
- Standard review: IRO decision within 40 days after the external review organization receives the request (§ 56-61-114)
- Expedited review: not more than 72 hours after receipt of a complete expedited request (§ 56-61-117); oral notice may be followed by written confirmation within 48 hours
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
TennCare medical appeals: File with TennCare Member Medical Appeals within 60 days (medical appeal instructions)—not commercial IRO review under Ch. 56-61.
TennCare eligibility appeals: 40-day window through TennCare Connect or written request—not the same as medical benefit appeals.
Provider–MCO payment disputes: A separate TennCare independent review process (§ 56-32-126) applies to providers disputing MCO claim denials—not to member benefit appeals.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.