What is independent review?
Independent review (external review) is a second look at certain final denials by an independent review organization (IRO) that is not your insurance company.
Depending on your plan, review may be administered by the Utah Insurance Department (UID)or by your carrier's certified IRO process. For eligible cases, the decision is generally binding on you and your plan.
General overview: Appeals roadmap. Complete Utah internal appeals first unless an urgent exception applies.
Who can use Utah review?
Independent review generally applies when:
- You have a UID-regulated commercial health benefit plan (many HealthCare.gov and fully insured employer plans)
- The dispute involves medical necessity, experimental/investigational treatment, or certain rescissions—not pure contractual or coding denials
- 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 (DHHS state fair hearing instead)
Important: Contact your carrier to learn whether UID or the plan administers independent review for your coverage. If you send a request to the carrier, it must forward it to UID within 1 business day when UID administers review (R590-261-8).
Deadlines & exhaustion
180-day filing window
File a written independent review request within 180 calendar days after you receive notice of a final adverse benefit determination (R590-261-8(a)). Federal law also sets a minimum four-monthwindow for many ACA plans—Utah's 180-day period aligns with that standard.
Exhaust internal appeal first
Complete internal appeal unless the carrier and you agree to waive it, or you qualify for deemed exhaustion under federal standards.
Expedited independent review
When delay would seriously jeopardize life or health or ability to regain maximum function, your treating provider must certify urgency. Expedited review must be completed within 72 hours after the IRO receives a complete request (UID form instructions).
Experimental / investigational treatment
Additional physician certification may be required on UID's Independent Review Request form for experimental or investigational denials.
How to file
- Complete internal appeal and obtain a final denial when required.
- Confirm whether UID or your carrier administers independent review (call the number on your denial letter).
- Download and complete UID's Independent Review Request form.
- Submit with your insurance card, final denial letter, medical records release, and clinical support to UID or your carrier per your notice.
UID submission options: mail 4315 S 2700 W, Suite 2300, Taylorsville, UT 84129 · email healthappeals.uid@utah.gov · fax (385) 465-6047
Guide: UID — independent review
Links hub: Utah external appeals links.
How long it takes
- Standard review: IRO decision within 45 days after the IRO is assigned (typical UID timeframe; allow up to ~55 days per department processing estimates)
- Expedited review: within 72 hours when medically urgent and properly certified
- If the carrier fails to provide records to the IRO, the IRO may reverse the denial (R590-261-8)
Is the decision binding?
For eligible medical-necessity and related 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.
UID can assist with complaints but generally does not overturn binding IRO decisions.
Medicaid & Medicare
Utah Medicaid: Exhaust MCO grievance/appeal, then request a state fair hearing within 120 days of the MCO final notice (Medicaid hearings)—not commercial IRO review under R590-261.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.