Independent External Review
Do I qualify for an Independent External Review?
To qualify for an Independent External Review:
- The patient must be covered by a contract issued in Virginia by a licensed health
carrier, or by a self-insured ERISA plan whose plan sponsor’s headquarters is located
in Virginia and the plan has elected to use Virginia’s External Review process.
- You must have exhausted the carrier’s internal appeal process. The process is deemed
to be exhausted in the following situations:
- All available internal appeals have been exhausted.
- The patient filed an appeal and has not received a response from the carrier on
its determination (unless a delay was agreed to) by either 30 days from the date
of filing a pre-service appeal, or 60 days from the date of filing a post-service
- A request for an expedited internal appeal of an adverse determination has been
filed with the health carrier. A simultaneous expedited External Review may be requested.
- The health carrier has agreed to waive the exhaustion requirement.
- The adverse determination for an admission, availability of care, continued stay,
or other health care services that is a covered benefit has been reviewed by the
health carrier or its designated review entity and has been determined to not meet
its requirements for medical necessity, appropriateness, health care setting, level
of care or effectiveness, or is determined to be experimental or investigational,
and the requested service or payment for the service is therefore denied, reduced
- A complete External Review request must be received by the Bureau of Insurance within
120 days after the date you received notice of your right to an External Review.
What types of coverage are not eligible for an
Independent External Review?
The following types of coverage are not eligible for Virginia's process of Independent
- Policies or certificates that provide coverage only for a specified disease, specified
accident or accident-only coverage;
- Disability income;
- Hospital indemnity;
- Long-term care;
- Dental, vision, or any other limited supplemental benefit or a Medicare supplement
policy of insurance;
- Plans through Medicare, Medicaid, or the federal employees health benefits program;
- Any coverage issued under Chapter 55 of Title 10 of the U.S. Code (TRICARE), and
any coverage issued supplemental to that coverage;
- Any coverage issued as supplemental to liability insurance, workers’ compensation
or similar insurance; and
- Automobile medical payment insurance or any insurance under which benefits are payable
with or without regard to fault, whether written on a group or individual basis.
Self-insured employee welfare benefit plans may choose to use Virginia’s process
for Independent External Review if the plan sponsor’s headquarters is located in
How does an Independent External Review work?
When the Bureau receives your appeal, it is sent to the health carrier or self-funded
plan contact involved to verify your request’s completeness and eligibility. If
any additional information is needed to complete your request or verify eligibility,
the health carrier/self-funded plan contact will request from you the specific information
needed. A timeframe will be given for you to submit this information. If you do
not submit this information to the entity requesting it in a timely manner, your
request may be terminated. If your request is determined to be ineligible, you may
appeal this determination to the Bureau.
After you have been notified that your request is complete and eligible for this
review process, the Bureau will randomly select an Independent Review Organization
(IRO) that is not affiliated with your carrier or self-funded plan, and has no conflict
of interest with your case to perform the review. For standard External Review requests,
once you are notified of the name of the IRO, you will be given 5 business days
from your receipt of this notification to submit any additional information you
would like reviewed regarding your case. Your health carrier/self-funded plan must
also submit all of its documents and information considered in making its determination
to the IRO for review. The IRO will issue its determination to the parties involved.
The decision is binding on the health carrier/self-funded plan, and on the covered
person except to the extent the covered person has other remedies available under
applicable federal or state law.
If a request for an expedited External Review is submitted when an expedited internal
appeal request has been made, the IRO will make a determination as to whether the
internal expedited appeal process must be completed prior to the expedited External
Review process beginning.
Forms for Consumers
External Review Request Form – Form 216-A
Appointment of Authorized Representative – Form 216-B
Physician Certification for Expedited External Review Request –
Physician Certification Experimental or Investigational Denials –
Forms for Independent Review Organizations:
Independent Review Organization Application – Form 216-E
Independent Review Organization External Review Annual Report –
Form for Health Carriers:
Health Carrier External Review Annual Report – Form 216-F
Form for Self-insured ERISA Plans:
Self-insured Plan Opt-in for External Review – Form 216-H