External Review for Health Claim Denials
Your right to an independent external review: Idaho consumers have the right to an independent external review of a health claim denial, if the health carrier denied the claim for these reasons:
- The medical necessity, appropriateness, health care setting, level of care or effectiveness of the service or supply; or
- The service or supply is investigational.
You must first exhaust all levels of internal appeals or grievances with your health carrier before you can apply for an external review – but you can file for an expedited appeal for an urgent care request simultaneously with the health carrier and the Idaho Department of Insurance (DOI).
No later than four months from the date of the health carrier’s final denial, you may submit a written request for an external review to the DOI. You must use Idaho’s:
If your request qualifies, the DOI will assign your request to an independent review organization (IRO) and notify your health carrier. The IRO will review your medical records and other relevant material received from your health carrier to determine if the health carrier made the correct decision. The IROs registered with the DOI are independent from health carriers. Your health carrier will pay the cost of the review. The IRO’s decision is binding on the health carrier.
Standard Review: The IRO must make a decision within 42 days after it receives a request from the DOI.
Expedited Review: For an urgent care request, send the External Review Request Form and Authorization to the DOI for an expedited review. The IRO must make a decision within 72 hours after it receives an expedited request from the DOI.
For more information: See our Frequently Asked Questions (FAQs)
Contact the DOI:
Idaho Department of Insurance
ATTN: External Review
700 W State St, 3rd Floor
Boise ID 83720-0043
Toll-free in Idaho: 1-800-721-3272
Fax: (208) 334-4398
Email: Consumer Affairs
Review the DOI Rule, Idaho Health Carrier External Review Act, IDAPA 18.01.05.