Home / Resources / Internal vs external review
Your right to appeal
Internal vs external review
A denial is not the final word. The Affordable Care Act gives almost everyone with health coverage two layers of appeal: first your insurer reconsiders, then a neutral outside reviewer decides, and that outside decision is binding. Here is each layer, in plain language.
This is general information about your rights, not legal advice. Your denial letter states the exact process for your plan.
When an insurer denies a claim, many people assume that is the end. It is not. Federal law gives you a defined right to challenge the decision, and to have someone outside the insurance company take a fresh look if the insurer says no again. Knowing the two layers, and the order they come in, is half the battle.
The Affordable Care Act guarantees two kinds of review for most health plans: an internal appeal, handled by your insurer, and an external review, handled by an independent organization. They are not interchangeable. You generally start with the internal appeal, and the external review is your escalation when the internal one fails.
The two layers, side by side
Internal review
- Who decides
- Your insurance company reconsiders its own decision, using a reviewer who was not involved in the original denial.
- What it is for
- Asking the plan to look again, with your full argument and any records that were missing the first time.
- Typical deadline to file
- Often 60 to 180 calendar days from the denial, depending on your plan. Your letter states the exact window.
- Typical decision time
- Commonly around 30 days for care you have not yet received, and 60 days for care already provided. Urgent cases are faster.
External review
- Who decides
- An independent review organization with no financial stake in the outcome, separate from your insurer.
- What it is for
- A neutral, final look after internal appeals are exhausted, especially for denials based on medical necessity.
- Typical deadline to file
- Generally up to four months after the final internal denial under the federal standard; some states differ.
- How binding it is
- The decision is binding on the insurer. If the reviewer overturns the denial, the plan must cover the service.
The detail people miss: the external reviewer's decision is binding on your insurance company. This is what makes external review such a meaningful right. It is not another customer-service conversation; it is a neutral party that the insurer must follow.
Layer one: the internal appeal
An internal appeal is your formal request that the insurer reconsider. You have the right to:
- Ask for the specific reason your claim was denied, and the criteria the plan used, in writing.
- Receive a copy of the documents and evidence relevant to your claim, free of charge.
- Submit additional information and have it considered by someone who was not part of the first decision.
- Name a representative, such as a family member or advocate, to help you through the process.
Some plans have one internal level; others have two. If your first internal appeal is denied and your plan offers a second level, you can usually pursue it before moving on.
Layer two: external (independent) review
If the internal appeals do not resolve it, external review puts the decision in neutral hands. The general path looks like this:
- 1Finish the internal appeals first.In most cases you must complete your plan's internal process before requesting external review, though urgent situations can sometimes run both at once.
- 2Request the external review in time.File within the window stated on your final denial, generally up to four months under the federal standard. Your final denial notice explains exactly how.
- 3An independent organization reviews the case.The reviewer is separate from your insurer and applies the relevant standards to your records and your plan's rules.
- 4The decision binds the insurer.If the external reviewer overturns the denial, your plan must provide coverage for the service in dispute.
One important nuance: the exact external-review path can depend on your state and your plan type. Some states run their own external review programs; in other cases a federal process applies. Your final denial letter tells you which one is yours and how to start it. The right exists either way.
How this maps to a GLP-1 denial
If your Wegovy, Zepbound, Ozempic, or Mounjaro claim was denied, these are the same two layers you move through. The internal appeal is where you answer your plan's coverage criteria with your records and the FDA label. If that does not succeed, external review is the independent backstop. The work, and the deadlines, carry across both. For the full sequence, see how to appeal a GLP-1 denial.
The magic is visible
An appeal that holds up at both layers is a grounded one.
Whether your case stops at the internal appeal or goes to external review, every citation should trace to a real source. On our held-out testing: 0 invented citations, versus about 1 in 4 for raw AI.
Sample appeal, built from real source types
- Your plan's coverage policyThe published criteria your insurer applied to the claimVerified
- Your rights under the ACAThe internal-appeal and external-review provisions that apply to your planVerified
- Your recordsYour diagnosis, history, and prior therapies, cited back accuratelyVerified
Let's use your rights, free.
Answer a few questions for an honest read on your options, then a verified draft for your internal appeal. No account, no cost.
Check my denial, free