External Review

Idaho consumers have the right to an independent external review of a health claim denial if the health insurance company has denied the claim for these reasons:

• medical necessity, appropriateness, health care setting, level of care, or effectiveness of the treatment, or
• treatment is investigational

You must exhaust all levels of internal appeals or grievances with your health insurance company before you can apply for an external review.  You may submit a written request for an external review to the Department of Insurance within, but not later than, 120 days (four months) from the date of the final denial by the insurance company.  You must use the following form:

• Health Claims External Review Request Form

If your request qualifies, the Department of Insurance will assign your request to an independent review organization (IRO) and notify your health insurance company.  The IRO will review your medical records and other relevant material received from your insurance company to determine if the insurance company made the correct decision.  The IROs registered with the Department of Insurance are independent from health insurance companies.  Your insurance company will pay the cost of the external review.  The IRO’s decision is binding on the health insurance company.

Standard Review: The IRO must make a decision within 42 days after it receives a request from the Department of Insurance.

Expedited Review: In certain circumstances, you may qualify for an expedited review.  To qualify for an expedited review, the treating health care provider must certify that a delay would seriously jeopardize the life or health of the patient or would jeopardize the patient’s ability to regain maximum function.

For an urgent care request, send the External Review Request Form and proper authorization to the Department of Insurance for an expedited review.  The IRO must make a decision within 72 hours after it receives an expedited request from the Department of Insurance.

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
(208) 334-4250
Toll-free in Idaho: 1-800-721-3272
Fax: (208) 334-4398
Email: Consumer Affairs

Review the Idaho Health Carrier External Review Act, Chapter 59 of Idaho Code Title 41.

Review the DOI Rule, Idaho Health Carrier External Review Act, IDAPA 18.04.01.