October 22, 2017
 
External Review Request 

This External Review Request template can be altered to fit your denial. For assistance with a completely researched, tailored letter, call the helpline @ 920.664.9407.
 
[Your name]
[Your address]
 
[Date]
 
[Address of your health plan’s appeal department]
 
RE:  [Name of the Insured]
Plan ID #: [123]
Claim #: [456]
 
To Whom It May Concern:
 
I’m requesting an external review by an independent review organization (IRO) of the final internal adverse benefit determination I received on [date], which is included with this appeal.  
I filed my internal appeal on [date], in response to [for example, a procedure I had done by the advice of my primary care physician which was not considered to be medically necessary].  
 
Your review board returned their ruling, upholding the original decision.
 
[After requesting the external review, this place in the letter is usually a good point to include anything that has come to your attention since you filed your first appeal.  For example, “In the process of filing an internal appeal, I learned that my primary physician was granted prior approval for my procedure as documented in the notes included in this appeal.”   Again, keep it fact-based, and to the point.]
 
I look forward to your direct response as soon as possible.
 
Sincerely,
 
[Your name]
 
Contact info