05 - Health Carrier External Review 2025

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For a standard external review, the MAXIMUS reviewer must give you written notice of the decision as soon as possible, but no more than 45 days after the reviewer receives your request for an external review.
External review: You have the right to take your appeal to an independent third party for review. This is called an external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
The act covers definitions, applicability, notice requirements, the external review process, approval and qualifications of independent review organizations, reporting requirements, disclosure, and other provisions to ensure consumers have access to an independent external review of certain health insurance coverage
What is an external review? External review is a process where you may seek an independent review of a health insurance company decision to refuse to pay for or authorize a treatment or service. External review is limited to health insurance company decisions based on medical necessity.
External review is the process by which OPM, or an Independent Review Organization if the case requires medical judgment, reviews a health insurance plans decision to deny a benefit or payment for a service for an enrollee in an MSP option.

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Consumers rarely appeal denied claims (fewer than 1% of denied claims were appealed) and when they do, insurers usually uphold their original decision (56% of appeals were upheld). Marketplace enrollees filed 5,000 external appeals in 2023, or 3% of all upheld internal appeals.
You file an external review: You must file a written request for an external review within four months after the date you receive a notice or final determination from your insurer that your claim has been denied.
The purpose of this Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Act.

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