External Review Eligibility Checker

ANA›Life Services Authority›National Calculator Authority›External Review Eligibility Checker

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External Review Eligibility Checker

Determine whether your health insurance claim denial qualifies for an external independent review under federal (ERISA/ACA) or state standards.

Type of Denial / Adverse Determination

-- Select -- Medical Necessity Denial Experimental / Investigational Treatment Rescission of Coverage Urgent Care / Expedited Review Coverage Exclusion (Clinical) Administrative / Non-Clinical Denial

Plan / Insurance Type

-- Select -- ERISA Self-Funded Employer Plan ACA Marketplace / Fully Insured Group Plan Grandfathered Health Plan Medicare / Medicare Advantage Medicaid / CHIP Short-Term Limited Duration Plan

Have you exhausted internal appeals?

-- Select -- Yes – internal appeal decision received No – but deemed exhausted (plan failed to follow rules) No – urgent/expedited care (simultaneous allowed) No – internal appeal not yet completed

Days Since Final Internal Appeal Decision (or Denial if Deemed Exhausted)

Federal deadline: 4 months (≈ 122 days) from receipt of final denial notice

Claim Amount in Dispute (USD)

Some states require a minimum claim amount (commonly $0 – $500)

State of Insurance / Plan Situs

Federal Only / Unknown State with Strong External Review Law (e.g., CA, NY, TX, IL) State with Basic / Limited External Review Law State with No External Review Law

Check Eligibility

function extCalc() { // --- Clear errors --- ['ext-denial-type','ext-plan-type','ext-internal-exhausted', 'ext-days-since-denial','ext-claim-amount'].forEach(function(id) { document.getElementById(id + '-err').textContent = ''; });

var denialType = document.getElementById('ext-denial-type').value; var planType = document.getElementById('ext-plan-type').value; var internalStatus = document.getElementById('ext-internal-exhausted').value; var daysRaw = document.getElementById('ext-days-since-denial').value.trim(); var amountRaw = document.getElementById('ext-claim-amount').value.trim(); var stateLaw = document.getElementById('ext-state-law').value;

var valid = true;

if (!denialType) { document.getElementById('ext-denial-type-err').textContent = 'Please select a denial type.'; valid = false; } if (!planType) { document.getElementById('ext-plan-type-err').textContent = 'Please select a plan type.'; valid = false; } if (!internalStatus) { document.getElementById('ext-internal-exhausted-err').textContent = 'Please select internal appeal status.'; valid = false; } if (daysRaw === '' || isNaN(Number(daysRaw)) || Number(daysRaw) 1) { notes.push('Expedited external review requests should be filed as soon as possible — typically promptly of the denial for urgent situations.'); }

if (days > FEDERAL_DEADLINE_DAYS) { var overBy = days - FEDERAL_DEADLINE_DAYS; issues.push('The federal filing deadline of 4 months (≈ 122 days) from the final denial notice has been exceeded by ' + overBy + ' day(s). Your request may be time-barred unless a state law provides a longer window.'); if (stateLaw === 'strong_state') { notes.push('Some states (e.g., California: 180 days; New York: 45 days from denial) have different deadlines. Verify your state's specific deadline.'); } else { eligible = false; } } else { var remaining = FEDERAL_DEADLINE_DAYS - days; notes.push('You have approximately ' + remaining + ' day(s) remaining within the federal 4-month filing window.'); }

// --- 5. Claim amount threshold --- // Federal: no minimum dollar threshold for external review // Some states impose minimums (commonly $100–$500) // We flag if amount = 100) }, ];

var passCount = criteria.filter(function(c){ return c.pass; }).length; var totalCriteria = criteria.length; var scorePercent = Math.round((passCount / totalCriteria) * 100);

// Final eligibility determination var eligibilityLabel, eligibilityColor, eligibilityIcon; if (eligible && passCount >= 4) { eligibilityLabel = 'Likely Eligible for External Review'; eligibilityColor = '#1a7a4a'; eligibilityIcon = '✅'; } else if (eligible && passCount === 3) { eligibilityLabel = 'Conditionally Eligible — Verify State Rules'; eligibilityColor = '#b07d00'; eligibilityIcon = '⚠️'; } else if (!eligible && stateLaw === 'strong_state') { eligibilityLabel = 'Federal Pathway Blocked — State Law May Apply'; eligibilityColor = '#b07d00'; eligibilityIcon = '⚠️'; } else { eligibilityLabel = 'Not Eligible for Standard External Review'; eligibilityColor = '#c0392b'; eligibilityIcon = '❌'; }

// Build criteria table var criteriaRows = criteria.map(function(c) { return '' + c.name + '' + (c.pass ? '✔ Pass' : '✘ Fail') + ''; }).join('');

var issueHTML = issues.length
? '' + issues.map(function(i){ return ''; }).join('') + ''
'No blocking issues identified.

';

var notesHTML = notes.length
? '' + notes.map(function(n){ return ''; }).join('') + ''
'';

var html = '### ' + eligibilityIcon + ' ' + eligibilityLabel + ' ' + 'Eligibility Score: ' + passCount + ' / ' + totalCriteria + ' criteria met (' + scorePercent + '%)

' + '' + 'CriterionResult' + '' + criteriaRows + '' + '#### Blocking Issues ' + issueHTML + (notesHTML ? '#### Important Notes ' + notesHTML : '') + 'This tool provides general guidance only and does not constitute legal advice. Consult a licensed insurance professional or attorney for case-specific determinations.

';

var resultDiv = document.getElementById('ext-result'); resultDiv.innerHTML = html; resultDiv.style.display = 'block'; }

#### Formula & Decision Logic

Federal Filing Deadline:

Deadline Date = Final Denial Date + 4 calendar months (≈ 122 days) Days Remaining = 122 − Days Since Final Denial Time-Barred if Days Since Denial > 122

Eligibility Score:

Score (%) = (Criteria Passed ÷ 5 Total Criteria) × 100

Criteria: 1. Plan type subject to ACA/ERISA external review rules 2. Denial involves medical/clinical judgment (not purely administrative) 3. Internal appeals exhausted OR a recognized exception applies 4. Request filed within 4-month federal deadline (≤ 122 days) 5. Claim amount ≥ $100 (common state minimum threshold)

Outcome Thresholds:

≥ 4 criteria + no blocking issues → Likely Eligible 3 criteria + no hard blocks → Conditionally Eligible Blocked federally + strong state → State Pathway May Apply < 3 criteria OR hard block → Not Eligible

#### Assumptions & References

More Calculators

References

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