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External Review

A review of a plan’s decision to deny coverage for, or payment of, a service by an independent third party. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process is not yet completed. External review is available when: the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; the plan determines that the care is experimental and/or investigational; or for cancellations of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The health plan must accept the decision of an external review.