What is independent review?
Certified independent review is a second look at certain final denials by an OIC-certified independent review organization (IRO) that is not your insurance company.
For eligible fully insured plans, the IRO decision is binding on the carrier (and final for you except where other legal remedies exist). The carrier pays IRO fees—you do not.
General overview: Appeals roadmap. Complete Washington internal appeals first unless deemed exhaustion or qualifying expedited review applies.
Who can use Washington review?
Washington IRO review under RCW 48.43.535 generally applies when:
- You have OIC-regulated commercial coverage (many Washington Healthplanfinder and fully insured employer plans)
- The dispute involves medical necessity, appropriateness, experimental/investigational treatment, or similar clinical judgments—not pure contractual exclusions or reimbursement-only disputes
- You exhausted internal grievance—or qualify for deemed exhaustion or simultaneous expedited review
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may apply—sometimes with longer IRO timelines)
- Medicare, Medicaid (Apple Health), and TRICARE
- Dental-only, vision-only, disability-income, and other non-health-plan products listed by OIC
Deadlines & exhaustion
120 days (WAC 284-43A-070)
File a request for independent external review within 120 days of notice of a final adverse determination (WAC 284-43A-070; RCW 48.43.535).
Exhaust internal grievance first
Complete the carrier's grievance process unless the carrier waived it, you qualify for expedited simultaneous review, or the carrier missed grievance timelines without good cause (deemed exhaustion).
Additional information to the IRO
After referral, you may submit additional information within 5 business days (standard) or 24 hours (expedited) per WAC 284-43A-070.
How to file
- Complete internal grievance and obtain a final denial with independent review rights when required.
- Submit a written request to your carrier as described in your denial letter (include member ID, denied service, and clinical support).
- The carrier must forward the case to a certified IRO within 3 business days (RCW 48.43.535).
- Contact OIC Consumer Advocacy at 800-562-6900 if you need help confirming eligibility or deadlines.
OIC guidance: How to appeal a health insurance denial.
Links hub: Washington external appeals links.
How long it takes
- Standard review: IRO decision within 15 days after receiving necessary information, or 20 days after referral, whichever is earlier (up to 25 days in exceptional incomplete-info cases)
- Expedited review: within 72 hours after referral
- Self-funded ERISA plans (when using Washington process): may allow up to 45 days per OIC appeals guide
- Carrier must send your internal appeal file to the IRO
Is the decision binding?
For eligible disputes, the IRO decision is binding on the health carrier. If the IRO overturns the denial, the plan must provide coverage consistent with the decision. The IRO decision is final for you except where other state or federal remedies exist.
Medicaid & Medicare
Apple Health: Exhaust MCO internal appeal, then request an HCA/OAH administrative hearing—generally within 90 days of the notice (HCA appeals)—not commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; free help from Washington SHIBA.
More: Medicaid managed care · Medicare appeals.