External review describes the process that provides you with an opportunity to have a health insurance claim dispute reviewed by experts who have no affiliation to your insurer. If you are denied coverage or payment under your health insurance plan, you can appeal to your insurer internally. Contact your insurer or look in your plan benefit packet for more information on how to file an internal appeal. If you are not satisfied with the outcome of your internal appeal, or if your insurer waives the internal appeal, you may request an external appeal.
The following questions provide general information about what is required by North Dakota law. If you have specific questions on how external review laws apply to your situation, please contact your insurance company or the North Dakota Insurance Department (NDID).
Who conducts external reviews?
Grandfathered plans (those issued prior to March 23, 2010): External reviews are conducted by the North Dakota Health Care Review, Inc., another peer review organization meeting the requirements of section 1152 of the Social Security Act, or any person designated by the Insurance Commissioner.
Non grandfathered plans (those issued March 23, 2010 or later): External reviews are conducted by Independent Review Organizations, or IROs, that are contracted by the Insurance Department. IROs are nationally certified, which shows that they are unbiased and have procedures to ensure that their reviewers are qualified and independent. Once you are determined to be eligible for an external review, the Insurance Department will randomly assign an IRO to review your request.
What types of disputes can be decided through external review?
Grandfathered plans: An external review can address whether medical care rendered was medically necessary and appropriate to the claim.
Non grandfathered plans: An external review can address a decision based upon requirements for medical necessity, appropriateness, health care setting; rescission; and level of care or effectiveness, including decisions against treatment that is experimental or investigational. There is no minimum dollar amount for the value of your claim for it to be eligible for external review.
When can I request an external review?
Grandfathered plans: In most cases, you will need to complete your insurer's internal grievance procedure before requesting an external review. Your insurance company may require external review applications to be submitted within a certain timeframe following the date of the denial.
Non grandfathered plans: Whenever your insurer makes a coverage denial determination that is eligible for an external review, it must provide you with information on your appeal rights, including its internal grievance procedures and your right to request an external review. It must also explain how you can obtain additional information on its internal grievance and external review processes. In most cases, you will need to complete your insurer's internal grievance procedure before requesting an external review. External review requests must be submitted within four months from the date of the denial, unless your insurer allows a longer period of time.
How do I request an external review?
After you receive the insurer's final decision on your internal appeal (if applicable), you can request an external review by filing a request with your insurer or the Insurance Commissioner.
What if I need care now?
Generally, you must complete an internal appeal procedure before requesting an external review. However, you do not need to complete this process if both you and the insurer agree to proceed directly to external review if you need immediate medical care.
Grandfathered plans: Your insurance company may provide an expedited external review process. North Dakota law does not require it.
Non grandfathered plans: If you need immediate medical treatment and believe that the time period for resolving an internal appeal will cause a delay that could jeopardize your life or health, you may ask to bypass the insurer's internal appeal process and apply for an expedited external review.
Is there a cost involved?
Grandfathered plans: If the independent external reviewer upholds the denial of a claim, the consumer is responsible to pay all costs associated with the external review.
Non grandfathered plans: An insurance company, nonprofit health services corporation or health maintenance organization may require the consumer to pay a nominal filing fee, not to exceed $25. The fee may be returned to the consumer if the claim denial is reversed.
How long does the external review process take?
Grandfathered plans: Your insurance company may process external reviews according to a specific schedule. North Dakota law does not mandate a timeframe in which external reviews must be completed.
Non grandfathered plans: Once your request has been determined to be eligible for external review, an IRO has up to 45 days to return a decision. However, in the case of an expedited review of an urgent medical decision, the IRO must return the decision within 72 hours of its receipt of a request.
How does the IRO make its decision?
The IRO must consider all of the documentation and other information provided by you and by the insurer, including medical or scientific evidence, the applicable insurance contract and any legal bases.
Does my health plan have to abide by the decision?
Yes, the outcome of an external review is binding.
What if I have more questions?
Your insurance company's customer service department should be able to answer any questions you may have regarding the external review process. You're also welcome to call the Insurance Department at 1-800-247-0560.