Welcome to the HHS-Administered Federal External Review Process website.
Under the Affordable Care Act, consumers now have rights to appeal health insurance plan decisions to deny payment for services or coverage of treatment. Under the law, many health plans must meet basic standards for how to handle internal appeals and external reviews.
An internal appeal is a review by the health plan itself. You may file an internal appeal to ask your health plan to reconsider its decision to deny your:
Request for approval to get a service or treatment (pre-authorization)
Claim for payment for a service or treatment
Application for health insurance coverage.
An external review is a review of the health plan's decision by an independent third party. Under the law, consumers now have rights to an external review. An external review is an easy way to appeal the health plan's denial.
This means that insurance companies no longer have the final say over many benefit decisions. An external review will either uphold the insurance company’s decision or decide in favor of the consumer by overturning all or some of the health plan's decision.
Sometimes an external review is called an external appeal. We will use the words external review on this website.
In some cases, the U.S. Department of Health and Human Services (HHS) administers the external review process. It is officially called the HHS-Administered Federal External Review Process. MAXIMUS Federal Services, Inc. is implementing this process for HHS.
Click Resources to see webinar slides about the Federal External Review Process.