How and When to file an External Review
Health Care Providers
You may file your external review request electronically via the Department’s Message Center at https://mc.insurance.illinois.gov/messagecenter.nsf. Please go to the section entitled, Health Care Providers, create an account, and file your request. You may use one account to file requests for multiple patients.
You may complete the fillable pdf forms below, then Save, Save & Email, or Save & Print.
- External Review Request form - Required for ALL instances.
- Health Care Provider Certification forms - Expedited | Experimental
- Appointment of Authorized Representative form - use to provide an appointment to another person for the review
- If you disagree with a health carrier's determination, regarding medical necessity, experimental/investigational, pre-existing condition or rescission of health coverage you may file a Request for External Review with the Illinois Department of Insurance.
- You must first exhaust your internal appeal rights before requesting an external review except in urgent circumstances.
- You must file for an external review within 4 months from the date of written notification that the internal appeal process has been exhausted.
House Bill 0224 gives covered persons the right to apply for an External Review for the denial, reduction, termination or failure to make payment under the health carrier's benefit plan for the following reasons:
- the service was not "Medically Necessary"; or
- the service is considered "Experimental/investigational"; or
- the condition is "Pre-existing"; or
- your coverage is being rescinded (voided) for a reason other than non-payment of premium or contributions;
You are not eligible for an external review under Illinois law if:
- you are covered by a self-insured employer plan, self-insured union plan, self-insured church plan or self-insured non-federal governmental plan unless the plan has opted for the state process;
- you are covered by a group plan which is issued in another state;
- the coverage is through Medicare, Medicaid, Federal Employees Health Benefits Program; Tricare or other military coverage;
- the coverage is for a specified disease (such as cancer only); specified accident or accident only, credit, dental, disability income, hospital indemnity, long-term care, vision, or other limited supplemental benefits. For more detailed information regarding external review, please see the External Review Fact Sheet or call (877)850-4740.