External review in Idaho: deadline, cost and how to ask

Step 2: Outside review in Idaho

Program

External Review (Idaho Health Carrier External Review Act)

Who runs it

• Idaho Department of Insurance (assigns an independent review organization): Individual and fully insured group health plans in Idaho

Deadline to ask

4 months

You must file within 4 months after the date your plan issued its final denial notice. Count from the date on the notice, not the date you got it.

The deadline runs from

The date the notice of the final adverse benefit determination (final denial) was issued

Do I have to appeal to my plan first?

You must first finish all levels of your plan's internal appeals or grievances. You are treated as having finished if the plan has not decided within 35 days (3 business days for an urgent pre-service or ongoing-care request), unless you agreed to a delay. You can skip the internal process if the plan agrees, if the plan did not give you a timely, full and fair chance to use its process, or if your condition is urgent and you apply for expedited external review at the same time as an expedited internal review.

When you can go without a plan answer

35 days after you file your internal appeal

How long the review takes

Standard: 42 days

Cost

Your insurance company pays the cost of the external review.

What can be reviewed

Denials based on medical necessity, appropriateness, health care setting, level of care or effectiveness of treatment, and denials of treatment as experimental or investigational. Coverage issues (the service is not covered, eligibility, payment limits), legal interpretation of plan language, and bad faith or extra-payment claims do not qualify.

Is the decision final?

For a plan not covered by ERISA (for example an individual policy or a government plan), the decision is final and binding on the insurer and on you, and no court case is allowed on the issues decided. For an ERISA (job-based) plan, it is binding on the insurer; if you go to court, the external review record becomes part of the court record.

How to ask

Fill out the Health Claims External Review Request Form and send it to Idaho Department of Insurance, ATTN: External Review, P.O. Box 83720, Boise, ID 83720-0043 (fax 208-334-4398), with a copy of your insurance ID card, a copy of the plan's final denial letter, and a copy of your certificate of coverage or benefit booklet. You can also deliver it to 700 W. State St., 3rd Floor, Boise. For an urgent request, add the treating provider's certification and call Consumer Affairs before sending it. To name a representative, complete the Appointment of Authorized Representative section of the form.

Law: Idaho Code 41-5907, 41-5908, 41-5909, 41-5910, 41-5915; IDAPA 18.04.01

Forms and online request

• Idaho DOI Health Claims External Review Request Form

Phone

208-334-4250 or 1-800-721-3272 (toll-free in Idaho)

Write my appeal: free letters

Letter: ask for external review