Idaho consumers have the right to an independent external review of a health claim denial, if the health insurance 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 exhaust all levels of internal appeals or grievances with your health carrier before you can apply for an external review.
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 form:
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: 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 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 Idaho Health Carrier External Review Act,
Chapter 59 of Idaho Code Title 41.
Review the DOI Rule, Idaho Health Carrier External Review Act,
External Review Requests - Annual Statistics
Need more info? Contact us at 208 334-4319 or email us .
Consumer Affairs Officers are available to answer your questions 8-5 M-F MST