External Review

Federal process

Health care reform regulations provide for an external review process. Once you have exhausted our internal appeals process, you or your authorized representative may be eligible for an external review by an independent review organization if the adverse determination on your claim involves medical judgment. We will provide you with the appropriate form for requesting an external review, if applicable, when we notify you of our internal appeal determination.

The external review process is as follows:

  1. You must request the external review by an independent review organization within four months of the date you received our final adverse determination.
    • Mail the completed External Review Request form, that we will supply to you, and a copy of the adverse benefit notification (the response letter to your internal appeal) to:
      BCBSM External Review Requests
      Blue Cross Blue Shield of Michigan
      600 Lafayette East — Mail Code 2004
      Detroit, MI 48231-2998
  2. We will randomly assign your request for external review to a contracted independent review organization within five days of receiving your request for external review.
  3. The IRO will notify you whether your request is accepted for external review.
  4. If accepted, the IRO will provide you with its determination within 45 days of its receipt.
  5. If the IRO needs additional information, you will be contacted directly.

We will abide by the decision of the independent review organization and will pay your claim if the IRO determines that the services are a benefit based on their medical judgment.

imp-info

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