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Health Insurance: External Review

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How to request an external review when your health insurance claim has been denied 

What is an external review? 

In an external review, an independent medical professional reviews a denied health insurance claim to determine whether a treatment is medically necessary. External reviews can also review requests for prior authorization that have been denied. If the independent medical expert decides that the treatment is medically necessary, then your insurance company must pay for that treatment, so long as it’s a treatment covered by the health plan. 

First, you must file an internal appeal with your health plan 

If you are denied coverage for a claim or request, contact your health plan first. Health plans provide a way for you to file an internal appeal. If the decision is not reversed or you remain dissatisfied, you have the right to request an external review. You must file an external review request within six months from the date your claim was denied

The external review process 

Commerce’s role in the external review process is to facilitate the review and support the consumer. The department does not perform the review. The physician or provider assigned to your external review will review your medical and insurance records to make a decision on whether the treatment in question is medically necessary. 

Commerce can help you with issues involving insurance companies and the health plans we regulate. Keep in mind that we don’t regulate all health plans or Medicare, Medical Assistance, or MinnesotaCare. If you’re not sure whether you can or should request an external review, go ahead and submit the paperwork. The Enforcement Division can help you with your next steps. 

File an external review 

To request an external review, please review and complete the application form. You can submit your application to the department in one of these ways: 

  • Recommended: Email the form to consumer.protection@state.mn.us 
  • Call the Commerce Department’s Consumer Services Center at (651) 539-1600 or (800) 657-3602 and speak with an insurance investigator 
  • Mail the form to: 

External Review Process Minnesota Department of Commerce
85 7th Place East
St. Paul, MN 55101

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