Most state insurance departments will review your request to be sure that it is eligible for external review before sending it on to an external reviewer.  Most states require that the issue at stake involve “medical necessity.”  That means that you and your doctor must believe a particular procedure, treatment, or prescription drug is essential for your health and recovery.  Your health plan, for a variety of reasons, may disagree.  For example, your plan may believe a particular treatment is ineffective for your condition, so it will not pay for it. 

You and your doctor may want a medical treatment, but your health plan will not cover the cost because it considers the treatment experimental or investigational.  Most states will allow you to submit this type of dispute to external review. 

Many states explicitly exclude disputes over coverage issues, such as whether you can use a non-network provider because no qualified network provider is available or whether you were actually enrolled in the health plan, though some states have a separate process for reviewing these non-medical necessity denials.  Section 5 of this Guide tells you more about what types of problems your state will allow you to appeal through external review.

Several states require that your dispute involve a minimum amount of money, usually from $100 to $500.  In other states, your right to appeal a claim is not limited by the amount of money involved.