October 18, 2019


External Review Request 

This external review request template can be tailored to fit your denial.
[Your name]
[Your address]
[Address of your health plan’s appeal department]
RE:  [Name of the Insured]
Plan ID #: [123]
Claim #: [456]
To Whom It May Concern:
I’m requesting an external review by an independent review organization (IRO) of the final internal adverse benefit determination I received on [date], which is included with this appeal.  
I filed my internal appeal on [date], in response to [for example, a procedure I had done by the advice of my primary care physician which was not considered to be medically necessary].  
Your review board returned their ruling, upholding the original decision.
[After requesting the external review, this place in the letter is usually a good point to include anything that has come to your attention since you filed your first appeal.  For example, “In the process of filing an internal appeal, I learned that my primary physician was granted prior approval for my procedure as documented in the notes included in this appeal.”   Again, keep it fact-based, and to the point.]
I look forward to your direct response as soon as possible.
[Your name]
Contact info

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