Independent External Review Request
What this letter does
This letter asks for an outside, independent review of a denial that your health plan refused to reverse. Use it after your internal appeal is finished. The reviewer’s decision is binding on the plan. Most people have four months from the final denial to ask.
Sample letter
Independent External Review Request
This is a sample, not your letter. The names and numbers are made up.
SAMPLE — not a real letter. Names, amounts, and account numbers are fictional.
June 15, 2026 Jordan Sample 123 Sample Street Anytown, ST 00000 Cascade Mutual Insurance Appeals Department P.O. Box 0002 Sampleville, ST 00002 RE: Request for independent external review — Member ID MEM-0000-SAMPLE; Claim CLM-0000-SAMPLE; MRI lumbar spine (CPT 72148), date of service March 3, 2026; final internal denial dated June 2, 2026 Sent via certified mail, return receipt requested Dear Appeals Department: I have exhausted the internal appeal process for the claim above. I filed an internal appeal on April 3, 2026; your final internal denial, dated June 2, 2026 and referencing appeal number APL-0000-SAMPLE, upheld the original denial on the ground that the service was "not medically necessary." This letter is my formal request for an independent external review of that decision, made within four months of the final internal denial. Under the Affordable Care Act, Public Health Service Act § 2719 and 45 C.F.R. § 147.136, I am entitled to have a medical-necessity denial reviewed by an Independent Review Organization that is not affiliated with the plan, and the IRO’s decision is binding on the plan. I ask that you: 1. Acknowledge this request in writing. 2. Forward the complete claim and appeal file, including all records I submitted and all reviewer notes, to an accredited IRO. 3. Identify in writing which external review process applies to my plan, my state’s process or the federal process administered by the Department of Health and Human Services, and provide the filing address and deadline for that process, so that I may file directly if necessary. The clinical basis for the service is set out in my April 3 appeal and the enclosed records: six weeks of failed conservative treatment, new neurological findings on examination, and imaging ordered by my treating physician consistent with the American College of Radiology Appropriateness Criteria for low back pain with radicular symptoms. I am submitting an updated letter from Dr. Alex Example dated June 10, 2026 for the IRO’s consideration. This is not an urgent request, and I am asking for a standard external review. Please confirm the referral to the IRO in writing to the address above. I will follow up if I have not received confirmation by July 15, 2026. Sincerely, Jordan Sample Enclosures: Final internal denial dated June 2, 2026; internal appeal dated April 3, 2026 with attachments; updated letter from Dr. Alex Example dated June 10, 2026When not to use it
Do not use it before you finish the plan’s own appeal, unless your situation is urgent. For urgent care you can ask for both at the same time.
This sample is here to read, not to copy. A letter only works with your own facts, dates, and account numbers.
BillFighter is not a law firm and this page is not legal advice. We are not lawyers. If you are being sued, or your situation is complicated, talk to a lawyer or a legal aid office.
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