External Review Eligibility Checker
Determine whether your health insurance claim denial qualifies for an external independent review under federal (ERISA/ACA) or state standards.
Federal deadline: 4 months (≈ 122 days) from receipt of final denial notice
Some states require a minimum claim amount (commonly $0 – $500)
Formula & Decision Logic
Federal Filing Deadline:
Deadline Date = Final Denial Date + 4 calendar months (≈ 122 days) Days Remaining = 122 − Days Since Final Denial Time-Barred if Days Since Denial > 122
Eligibility Score:
Score (%) = (Criteria Passed ÷ 5 Total Criteria) × 100 Criteria: 1. Plan type subject to ACA/ERISA external review rules 2. Denial involves medical/clinical judgment (not purely administrative) 3. Internal appeals exhausted OR a recognized exception applies 4. Request filed within 4-month federal deadline (≤ 122 days) 5. Claim amount ≥ $100 (common state minimum threshold)
Outcome Thresholds:
≥ 4 criteria + no blocking issues → Likely Eligible 3 criteria + no hard blocks → Conditionally Eligible Blocked federally + strong state → State Pathway May Apply < 3 criteria OR hard block → Not Eligible
Assumptions & References
- ACA §2719 / 45 CFR §147.136: Establishes federal external review requirements for non-grandfathered group and individual health plans.
- ERISA §503 / DOL Reg. 29 CFR §2560.503-1: Governs internal claims and appeals for ERISA plans; federal external review applies via ACA for non-grandfathered plans.
- 4-Month Deadline: Under 45 CFR §147.136(d)(2)(i), a claimant must file for external review within 4 months of receiving the final internal appeal denial notice.
- Deemed Exhaustion: If a plan fails to strictly comply with internal appeal requirements, internal remedies are deemed exhausted (45 CFR §147.136(b)(2)(ii)).
- Expedited/Urgent Review: Must be completed within 72 hours; may be filed simultaneously with internal appeal for urgent care situations.
- Grandfathered Plans: Exempt from ACA external review mandate (ACA §1251); state law may independently apply.
- Administrative Denials: External review applies only to adverse benefit determinations involving medical judgment, not purely procedural/administrative denials.
- State Laws: States with approved external review programs may have different deadlines, thresholds, and covered plan types. NAIC Uniform Health Carrier External Review Model Act serves as the baseline.
- Medicare/Medicaid: Use separate federal/state appeals processes outside the ACA external review framework.
- This tool reflects federal standards as of 2024. State-specific rules vary; always verify with your state insurance commissioner or a licensed professional.