External Review Overview

Insurers offering comprehensive, fully-insured health benefit plans in Oregon must allow enrollees to appeal denials of coverage to independent review organizations (IROs). IRO's are independent of the insurers. They review medical records and other relevant materials to determine if the insurer made the correct decision.

Under external review, an enrollee in a health plan may ask an insurer for an independent external review of an adverse decision by the insurer. Often, the decision concerns whether a plan of treatment is:

• Medically necessary
• Experimental or investigational
• An active course of treatment for purposes of obtaining continuity of care under ORS 743.854.

An enrollee applies for an external review directly with his or her health insurance company or managed care organization. A request for external review must be made no later than 180 days after the date that the enrollee has received the insurer's final written decision following its internal appeal process. Enrollees are eligible for external review only after exhausting the health plan's internal appeal procedures, unless the insurer and enrollee agree to go directly to external review.

After an enrollee requests external review, the insurer submits an External Review Request Form to the Insurance Division. External reviews are randomly assigned to one of the IRO's with an approved contract.

The IRO first determines if the dispute qualifies for external review. If so, it reviews the dispute and issues a written decision based on expert medical judgment. The IRO must consider the enrollee's medical record, the recommendations of each of the enrollee's medical providers, relevant scientific and cost-effectiveness evidence, and standards of medical practice in the United States.

An IRO has 30 days to issue a decision after the enrollee applies to the insurer for an external review. However, in cases where the doctor certifies that the enrollee's life or health would be seriously jeopardized under the ordinary external review timeframe, an insurer may request an expedited review. For expedited reviews, a decision must be issued within three days of the request.

Insurers are bound by IRO decisions. However, patients may pursue legal action as a last option to overturn a denial.

IRO's are required to provide DCBS with a brief description of each decision, and an annual report summarizing their review outcomes.

If you have questions about external review, please contact Rhett Stoyer, at rhett.b.stoyer@state.or.us or (503) 947-7208.