Getting a denial from an employer health plan can feel like hitting a wall, especially when the care at issue involves surgery, cancer treatment, infusion therapy, residential treatment, imaging, or another high-cost recommendation. In many ERISA-governed health plans, a denial does not always end the process. In certain situations, a claimant may have the right to ask for an independent external review by an organization outside the plan.
This process can be technical. Deadlines can be short. The denial notice may refer to an “adverse benefit determination,” an “IRO,” a “final internal adverse benefit determination,” or an “expedited external review,” without explaining those terms in plain English.
In this post you’ll learn how to request external review after an ERISA health plan denial, what documents people often gather, which deadlines tend to matter most, when an urgent request may be available, and where an attorney may fit into the process. If you want a broader overview first, it may help to start with this plain-language explanation of what independent review rights often look like after a coverage denial.
<aside> 💡 Scroll to the bottom for every post in this series.
</aside>
ERISA generally governs many employer-sponsored health plans. When a claim is denied, the plan usually gets the first chance to review its own decision through an internal appeal. For non-grandfathered health plans, federal law also requires an external review process for certain denials, handled by an independent party rather than the plan itself, according to the U.S. Department of Labor and CMS (DOL, CMS).
That independent step can be important because the reviewer is supposed to evaluate the denial outside the plan’s internal structure. CMS explains that external review commonly applies to denials involving medical judgment, denials based on a finding that treatment is experimental or investigational, and certain rescissions of coverage (HealthCare.gov).
For many families, the practical issue is simple: the plan said no, the treating doctors disagree, and the medical and financial stakes are serious. External review is often the moment when the dispute moves from the insurer or plan administrator’s internal process to a neutral reviewer.
Not every ERISA health plan follows the same external review path.
The first big question is whether the plan is non-grandfathered. The Department of Labor’s current compliance guidance states that the external review provisions do not apply to grandfathered health plans (DOL PDF). If the denial notice mentions grandfathered status, that detail may affect whether external review is available at all.
The second question is whether the plan is:
That distinction often determines which external review system applies. The Department of Labor explains that non-grandfathered self-insured ERISA plans generally follow the federal private accredited Independent Review Organization (IRO) process, while insured coverage generally follows the state external review process if the state process meets federal standards (DOL PDF).
In other words, two employees with “ERISA plans” may both have external review rights, but one person’s request may go through a state-run system and another person’s may go through a private accredited IRO process tied to federal rules.
This is where many external review requests begin to take shape.
Under Department of Labor guidance, a denial notice generally includes: