UnitedHealthcare External Review: State-by-State Guide
External review is your best chance to overturn a UHC denial. Independent reviewers who aren't paid by UnitedHealthcare overturn their denials 40-50% of the time—far higher than internal appeals.
Best of all: it's completely free for you, and the decision is binding on UHC.
What is External Review?
External Review Basics
Independent Third Party: A reviewer not employed by or paid by UnitedHealthcare evaluates your case
De Novo Review: Fresh look at all evidence, not just rubber-stamping UHC's decision
Binding Decision: If external reviewer approves your claim, UHC must provide coverage
No Cost: Free for you; UHC pays the reviewer's fees
Timeline: Typically 45-60 days for standard review, 72 hours for urgent cases
Who Qualifies for External Review?
You can request external review if:
- ✅ UHC denied your internal appeal
- ✅ Denial involves medical judgment (medical necessity, experimental/investigational)
- ✅ You've exhausted internal appeals (or UHC violated timelines)
- ✅ Claim is for health care services (not administrative issues like eligibility)
Note: Some states allow external review for any adverse benefit determination, not just medical necessity.
External Review Success Rates
Why external review works:
- Reviewers have no financial incentive to deny claims
- They're typically medical experts in the relevant specialty
- They review actual medical evidence, not just UHC policies
- No conflict of interest with the insurance company
How to Request External Review
Step 1: Check Your Deadline
Most states require external review request within 4 months (120 days) of final internal appeal denial. Some states allow up to 180 days.
Don't delay: Start immediately after receiving internal appeal denial.
Step 2: Determine Process for Your State
External review is governed by state law (for most plans) or federal ACA (for some plans). Process varies by state.
Important: ERISA Plans and External Review
If you have employer-sponsored coverage, your plan may be governed by ERISA. Most states now allow external review for ERISA plans too, but check your state's rules.
The Affordable Care Act (ACA) requires external review for all non-grandfathered plans, including ERISA plans.
Step 3: Submit Request
You can usually request external review by:
- Through UHC: Send written request to UHC (they must forward to state or independent reviewer)
- Through your state: Contact your state Department of Insurance directly
- Online: Some states have online portals
Step 4: Gather Supporting Evidence
External reviewer will consider:
- All documents from internal appeal
- Any new evidence you submit
- Medical records and physician letters
- Clinical guidelines and peer-reviewed studies
- Your plan documents
Pro tip: Submit a comprehensive written statement explaining why denial is wrong, with supporting medical evidence.
Step 5: Wait for Decision
- Standard review: 45-60 days in most states
- Expedited review: 72 hours for urgent cases
State-by-State External Review Information
Special Situations
Expedited External Review
Request expedited review if:
- Delay would seriously jeopardize your life or health
- Delay would seriously jeopardize your ability to regain maximum function
- Standard timeframe would subject you to severe pain
- You're undergoing a current course of treatment (concurrent care)
Timeline: 72 hours for decision in most states
Experimental/Investigational Denials
Many states have special standards for external review of experimental/investigational denials:
- Reviewer must be medical expert in relevant specialty
- Must consider all medical literature, not just FDA approval
- Terminal illness may have relaxed standards
- Life-threatening conditions get priority review
Mental Health and Substance Use
External review for mental health/substance use denials must:
- Apply same standards as physical health
- Reviewer must have mental health expertise
- Mental Health Parity Act protections apply
What Happens After External Review?
If You Win
- ✅ UHC must provide coverage as determined by external reviewer
- ✅ UHC must notify you and your provider within specified time
- ✅ Decision is binding on UHC (they cannot appeal)
- ✅ If you've already paid, UHC must reimburse you
If You Lose
- Decision is final for that external review process
- You may have other options:
- Request a new external review if you have new medical evidence
- File complaint with state Department of Insurance
- For ERISA plans: consider federal lawsuit (consult attorney)
- For Medicare Advantage: appeal to next level (ALJ hearing)
Tips for Winning External Review
- Get physician support: Detailed letter from treating doctor is crucial
- Cite clinical guidelines: NCCN, medical society guidelines supporting treatment
- Provide peer-reviewed studies: Medical literature showing efficacy
- Show you meet UHC's criteria: Address every element of their medical policy
- Explain why alternatives failed/inadequate: Document what you've already tried
- Submit comprehensive evidence: Don't assume reviewer has everything from internal appeal
- Highlight UHC errors: Point out factual mistakes or policy misapplication
- For experimental denials: Show medical acceptance even if not FDA-approved for your specific use
Medicare Advantage External Review
If you have UHC Medicare Advantage, external review process is different:
IRE (Independent Review Entity)
- Automatic: Denial of certain services triggers automatic IRE review
- Timeline: Request within 60 days of denial
- Decision: 30 days for standard, 72 hours for expedited
- Binding: IRE decision is binding on UHC
If IRE Denies
You can appeal further to:
- Administrative Law Judge (ALJ): For claims over $180 (2024 threshold)
- Medicare Appeals Council: If ALJ denies
- Federal Court: For claims over $1,850
Resources:
- 1-800-MEDICARE: Help with Medicare appeals
- CMS Medicare Appeals: cms.gov/medicare/appeals-and-grievances
Common Questions
Do I need a lawyer for external review?
No. External review is designed to be accessible without legal representation. However, for very large claims or complex cases, a patient advocate or attorney can help strengthen your submission.
Can I submit new evidence during external review?
Yes. Unlike internal appeals where UHC controls what they review, external review allows you to submit any relevant medical evidence, including evidence that wasn't available during internal appeal.
What if UHC doesn't follow the external review decision?
File a complaint with your state Department of Insurance immediately. Also contact the external review organization. Failure to comply with binding external review decision is a serious violation.
Can I request external review for a partial denial?
Yes. If UHC approved some but not all of requested treatment (e.g., 10 days instead of 30 days), you can seek external review for the denied portion.
How is the external reviewer chosen?
Most states use independent review organizations (IROs) accredited by national accreditation bodies. Reviewer must have appropriate medical expertise and no conflict of interest with UHC.
File a Parallel Complaint
While pursuing external review, also file a complaint with your state Department of Insurance:
Why File a Complaint
- Creates regulatory pressure on UHC
- State may investigate UHC's denial patterns
- Patterns of complaints can trigger enforcement action
- Provides additional avenue for resolution
How to File
- Online: Most state DOIs have online complaint forms
- Phone: Call your state DOI consumer helpline
- Mail: Send written complaint to DOI
Find your state DOI: NAIC State Insurance Departments