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Click ‘Get Form’ to open the EXTERNAL APPEAL APPLICATION in the editor.
Begin with Section I, providing your personal information such as your full name, address, daytime telephone number, birth date, and email address. Ensure all details are accurate for effective communication.
Move to Section II and enter your insurance information. Confirm that you are covered by a fully-insured plan issued in New Jersey. Fill in the insurance company name, policy number, and ID number as they appear on your member card.
In Section III, indicate the type of appeal you are filing (Expedited or Standard) and confirm whether you have received a final written decision from your carrier. If not, provide an explanation.
Complete Section IV with the contact information of the person filing the appeal if it is not you. This includes their name, relationship to you, and contact details.
Sections V and VI require signatures for consent regarding medical records. Make sure these sections are signed appropriately before submission.
Finally, review all sections for completeness and accuracy before submitting your application via mail or email as instructed at the top of the form.
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To file a request for External Review: Download and complete the External Review Intake Form and, if applicable, the Authorized Representative Form (see below for more information about authorized representatives). You may call OPM toll free at (855) 318-0714 if you need help with your request for External Review.
What is an external appeal?
If your health insurance company is using the HHS-Administered Federal External Review Process, theres no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge cant be more than $25 per external review.
What does external appeal mean?
An external appeal is an independent review process, where an external third-party entity (usually a state or federally approved organization) evaluates the insurers decision after the internal appeal process has been exhausted. An external reviewer, who is independent from the insurer, makes the final determination.
How much is an external appeal fee?
The standard external review process can take up to 45 days from the date the patients request for external review is received by our department.
How long does an external review take?
If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the companys decision and have it reviewed by a third party. You can ask that your insurance company reconsider its decision. Insurers have to tell you why theyve denied your claim or ended your coverage.
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How to file an external appeal?
Visit externalappeal.cms.gov. Youll be able to file a request using a secure website. For claimants who are able to do so, the portal is the preferred method of submission for review requests. Call toll free: 1-888-866-6205 to request an external review request form.
Related links
Rule 15.22: Appendix B External Review Request Form
To complete this request, your treating health care provider must fill out the attached form stating that a delay would seriously jeopardize the life or health
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