Glossary
External review
In one sentence
A review by an independent body outside your plan, after the plan's own appeals are finished. Whether your state's process or the federal one governs depends on your plan's type, not on where you live.
Also written as Independent external review, IRO review.
What external review actually means
External review is the step where someone who does not work for the plan looks at the decision. It comes after the internal appeals, and it is the point at which the plan stops being both the decider and the referee.
Which process applies is the part people get wrong, and the reason is that it does not follow geography alone. A state process governs where the state's own process meets a minimum standard and binds the issuer. A self-insured employer plan may sit outside that process entirely, because state insurance law does not reach it, in which case the federal process applies instead. Two neighbors in the same state with the same employer's name on their cards can be on different tracks if one plan is insured and the other is self-funded.
Our answers page on this works through the distinction; the definition below is the rule that draws it.
The text it comes from
This is the wording the definition rests on. Where it decides anything for you, read the section rather than our summary of it.
A state process displaces the federal one only where it meets a floor. "If a State external review process that applies to and is binding on a health insurance issuer offering group or individual health insurance coverage includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the issuer must comply with the applicable State external review process and is not required to comply with the Federal external review process of paragraph (d) of this section."
45 CFR §147.136(c)(1)(i), Electronic Code of Federal Regulations, effective August 2026 · source
Where no state process reaches the plan, the federal one applies: "A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process in accordance with this paragraph (d)." The rule treats self-insured plans separately, noting a self-insured plan may be subject to a state process where that process "applies to and is binding on the plan (for example, is not preempted by ERISA)."
45 CFR §147.136(c) and (d), Electronic Code of Federal Regulations, effective August 2026 · source
Where this comes from
- 45 CFR §147.136(c)(1)(i), Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-45/part-147/section-147.136
Where this comes up
- State or federal appeal rights?
- Appealing a commercial denial
- Self-funded plan
- Every term we have defined
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page says what a published rule means by a word. Which rulebook governs you depends on your plan, and your own notice and plan documents govern your case.