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People also ask
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What does external review mean?
What is an external review? External review is a process where you may seek an independent review of a health insurance company decision to refuse to pay for or authorize a treatment or service. External review is limited to health insurance company decisions based on medical necessity.
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How long does an external review take?
Standard external reviews are decided as soon as possible – no later than 45 days after the request was received.
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How long does an external review take?
external reviews generally will be decided within 30 calendar days of the request. Expedited reviews are available when a member's physician certifies that a delay in service would jeopardize the member's health.
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What is a federal external review?
External review is the process by which OPM, or an Independent Review Organization if the case requires medical judgment, reviews a health insurance plan's decision to deny a benefit or payment for a service for an enrollee in an MSP option.
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What is the HHS administered federal external review process?
The HHS-Administered Federal External Review Process applies to “adverse benefit determinations,” including those that involve medical judgment (including, but not limited to, those based on the plan's or issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness ...
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How do I file an external appeal?
Visit externalappeal.cms.gov. You'll be able to file a request using a secure website. For claimants who are able to do so, the portal is the preferred method of submission for review requests. Call toll free: 1-888-866-6205 to request an external review request form.
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What is the external review of the No Surprises Act?
The No Surprises Act (NSA) expanded external review rights by ensuring that: ➢ Any adverse benefit determination that involves consideration of whether a plan or issuer is complying with surprise billing and cost-sharing protections under the NSA is eligible for external review.
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What is an external appeal?
If an insurance company upholds its decision to deny payment, the law provides consumers with the right to appeal the decisions to an outside, independent decision-maker, regardless of the type of insurance or state an individual lives in.
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