What is external review?
Independent external review is a free second look at certain final denials. The SCC Bureau of Insurance randomly assigns an independent review organization (IRO) that is not your insurance company.
For eligible cases, the IRO decision is binding on the health carrier (and on you except where other legal remedies exist).
General overview: Appeals roadmap. Complete Virginia internal appeals first unless an expedited or deemed-exhaustion exception applies.
Who can use Virginia review?
SCC external review generally applies when:
- You have a Virginia-regulated commercial health plan (many HealthCare.gov and fully insured employer plans)
- The denial is based on an eligible reason—such as medical necessity, experimental/investigational treatment, or similar clinical judgments (not pure reimbursement or contractual exclusions)
- You exhausted internal appeal—or qualify for waiver, deemed exhaustion, or expedited cancer review
Usually does not apply to:
- Medicare, Medicaid, and TRICARE
- Self-funded ERISA plans (unless the plan opts into Virginia external review and meets SCC requirements)
- Dental, vision, or limited supplemental benefits
- Pure out-of-network denials (unless based on medical necessity; some surprise-bill disputes use federal No Surprises Act review)
Deadlines & exhaustion
120 days
A complete external review request must be received by the Bureau within 120 days after the date you received notice of your right to external review (§ 38.2-3561).
Exhaust internal appeal first
Complete the carrier's internal appeal unless you qualify for expedited external review (including some cancer treatment denials before exhaustion) or deemed exhaustion when the carrier misses the 30-day internal appeal deadline without your agreement to delay (§ 38.2-3559).
Two review tracks
Standard review: you may submit additional information within 5 business daysafter SCC's assignment letter. Expedited review: faster IRO decision but you generally cannot add materials after filing (see SCC external review page for current rules).
How to file
Contact the Bureau before submitting—staff can confirm eligibility and required forms (877-310-6560 · externalreview@scc.virginia.gov).
- Complete internal appeal and obtain a final denial with external review rights when required.
- Download and complete Form 216-A (External Review Request).
- Add supporting forms if needed: 216-B (authorized representative), 216-C (expedited certification), 216-D (experimental/investigational).
- Include your final denial letter, insurance card copy, and clinical records.
- Submit per current instructions on the SCC external review page. External review is free to consumers.
Links hub: Virginia external appeals links.
How long it takes
- Standard review: IRO decision within 45 days; you may submit additional materials within 5 business daysafter SCC's assignment letter
- Expedited review: within 72 hours for medical necessity or 6 business days for experimental/investigational disputes
- The carrier must send your internal appeal file to the IRO for review
Is the decision binding?
For eligible disputes, the IRO decision is binding on the health carrier and on you, except to the extent you have other remedies under state or federal law. If the IRO overturns the denial, the plan must cover the service consistent with the decision.
Medicaid & Medicare
Medicaid: Exhaust MCO internal appeal, then request a DMAS state fair hearing—often within 120 days of the MCO final decision (DMAS appeals)—not SCC commercial external review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.