When can a patient request an external independent review of a claim?

A patient can request an external independent review of a claim after an internal appeal has been denied. This process is established to ensure that patients have the right to challenge the decisions made by their insurance providers regarding the medical necessity of services covered under their policy.

In most cases, patients are first required to exhaust their internal appeals process with the insurance company. This means they have to provide the insurer with an opportunity to re-evaluate the claim based on additional information or clarification. If the outcome of that appeal is unfavorable—meaning the claim is still denied—the patient then has the option to request an external review. This external review is intended to provide an impartial evaluation of the claim and can often lead to a different outcome than the internal review process.

The other options presented, such as initiating a request for an external review after submitting the initial claim, before an internal appeal, or during the billing process, do not align with the established protocol of the appeals process. They do not allow for a formal external review to take place unless the insurance company has already made a decision that has gone through internal appeals.

Understanding this process is crucial for patients as it provides them with an additional layer of protection and recourse when navigating insurance claims and denials.