What is external review?
Independent external review is a second look at certain final denials by a DFR-contracted independent review organization (IRO) that is not your insurance company.
For eligible cases, the IRO decision is binding on the insurer. DFR collects documents from you and the carrier and assigns the review.
General overview: Appeals roadmap. Complete Vermont internal appeals first unless waiver or deemed waiver applies.
Who can use Vermont review?
DFR external review generally applies when:
- Your plan's process is administered by DFR (confirm with your carrier—some plans use carrier-run IRO review)
- The denial is an appealable decision—medical necessity, experimental/investigational treatment, improper provider restriction, off-label drug use, or certain pre-existing condition determinations for covered benefits
- You exhausted first-level internal grievance—or qualify for waiver or deemed 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 / Green Mountain Care (state fair hearing—not commercial IRO review)
- Pure contractual or coding denials with no medical judgment
Deadlines & exhaustion
120 days or 4 months (whichever is longer)
File a written request with DFR within 120 calendar days or 4 months, whichever is longer, after you receive the final internal grievance decision, the insurer waives grievance, or the insurer is deemed to have waived grievance by missing deadlines (Rule H-2011-02 § 5(D)).
Exhaust internal grievance first
Complete the insurer's first-level internal grievance unless waived or deemed waived for missed timeframes.
Expedited external review
Available when delay would seriously jeopardize life, health, or ability to regain maximum function. You may file expedited external review simultaneously with an urgent internal grievance. IRO must decide within 3 days after DFR assigns the case (Rule H-2011-02).
How to file
- Complete internal grievance and obtain a final denial when required.
- Download DFR's Healthcare External Appeal form (Request an appeal).
- Include a medical records release, insurance card copy, final denial letter, and clinical support.
- Pay the $25 filing fee if required (may be waived for financial hardship; refunded if you win).
- Mail to DFR or follow current instructions on the external appeal page. Do not send medical records over unsecured email—DFR will provide secure upload instructions.
DFR: 89 Main Street, Montpelier, VT 05602 · 800-964-1784
Links hub: Vermont external appeals links.
How long it takes
- Standard review: IRO decision within 30 days after receiving all documentation (Rule H-2011-02)
- Expedited review: within 3 days after DFR assigns the case for urgent/emergency services
- DFR accepts complete applications within 5 business days of receipt
Is the decision binding?
For eligible disputes, the IRO decision is binding on you and your health insurer. If the IRO overturns the denial, the plan must provide coverage consistent with the decision. The insurer pays the cost of the independent review.
Medicaid & Medicare
Medicaid / Green Mountain Care: Internal appeal within 60 days, then state fair hearing within 120 days of the appeal resolution (DVHA appeals)—not DFR commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.