External Review
An External Review is a free service to help you if your insurance company denies coverage of certain covered benefits as explained below. For these benefits, it is the last option for contesting an insurance company’s denial outside of the legal system and, in most cases, can be used after you have exhausted the insurance company’s appeal process.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.
Please contact us before you submit a request or if you have questions.
- 1-877-310-6560 (toll free)
- externalreview@scc.virginia.gov
- You must be covered by a fully insured plan issued in Virginia or a self-insured plan which has opted-in to Virginia’s External Review process.
- You must have exhausted your insurance company’s appeal process.
- You may request an expedited external review before exhausting your insurance company’s appeals process if you have received a denial involving treatment of cancer
- You have received a denial based on an eligible reason, such as:
- The service is not medically necessary
- The service is not covered because it is experimental or investigational
- Ineligible reasons for External Review include:
- reimbursement disputes
- contractual exclusions
- out of network denials (unless based on “not medically necessary”. However, out-of-network payment denials may be eligible for the federally-administered No Suprises Act external review)
- The types of coverage not eligible for External Review include:
- Medicare, Medicaid, or TRICARE
- Dental, vision, or any other limited supplemental benefit
- Self-insured employee welfare benefit plans, unless the plan opts-in to use Virginia’s External Review process and the company’s headquarters is located in Virginia
- Contact the Bureau of Insurance to discuss your situation before you submit your request. We will also provide guidance on which additional forms may be needed.
- 1-877-310-6560 (toll free)
- externalreview@scc.virginia.gov
- Submit a completed External Review Request Form (Form 216-A) using the instructions provided on the form.
- Standard
- The Independent Review Organization (IRO) will decide within 45 days
- You have 5 business days from the date of your receipt of our letter to submit any information you want reviewed by the IRO
- Expedited
- The IRO will decide within 72 hours (for review of medical necessity) or 6 business days (for review of experimental/investigational)
- You cannot provide additional materials or information to the IRO
External Review Request Form – Form 216-A
Additional Forms:
Appointment of Authorized Representative – Form 216-B
Physician Certification for Expedited External Review Request – Form 216-C
Physician Certification Experimental or Investigational Denials – Form 216-D
We will send your request to the plan to review for eligibility.
When the ER is completed, the IRO will notify all parties of their decision to either uphold or overturn the denied service. The IRO’s decision is binding on the plan, and on the covered person except to the extent the covered person has other remedies under state and federal law.
- If your request is incomplete, the plan will request the needed information. If you do not respond, your request may be terminated
- If the plan determines your request is not eligible, you may appeal to the Bureau
- Select, randomly, an Independent Review Organization (IRO) without a conflict of interest to perform the ER
- Send you a letter with the name of the IRO and the timeframe for the process
When the ER is completed, the IRO will notify all parties of their decision to either uphold or overturn the denied service. The IRO’s decision is binding on the plan, and on the covered person except to the extent the covered person has other remedies under state and federal law.