Model Notice of Final
Internal Adverse Benefit Determination – Revised as of July 3, 2014
Important Information about Your Rights to External Review
What if I need help understanding this denial?
Contact us [insert contact information] if you need
assistance understanding this notice or our decision
to deny you a service or coverage.
What if I don’t agree with this decision? For
certain types of claims, you are entitled to request
an independent, external review of our decision.
Contact [insert external review contact information]
with any questions on your rights to external
review. [For insured coverage, insert: If your claim
is not eligible for independent external review but
you still disagree with the denial, your state
insurance regulator may be able to help to resolve
the dispute.] See the “Other resources section” of
this form for help filing a request for external
review.
How do I file a request for external review?
Complete the bottom of this page, make a copy, and
send this document to {insert address}.] [or] [insert
alternative instructions.] See also the “Other
resources to help you” section of this form for
assistance filing a request for external review.
What if my situation is urgent? If your situation
meets the definition of urgent under the law, the
external review of your claim will be conducted as
expeditiously as possible. Generally, an urgent
situation is one in which your health may be in
serious jeopardy or, in the opinion of your
physician, you may experience pain that cannot be
adequately controlled while you wait for a decision
on the external review of your claim. If you believe
your situation is urgent, you may request an
expedited external review by [insert instructions to
begin the process (such as by phone, fax, electronic
submission, etc.)].
Who may file a request for external review?
You or someone you name to act for you (your
authorized representative) may file a request for
external review. [Insert information on how to
designate an authorized representative.]
Can I provide additional information about my
claim? Yes, once your external review is initiated,
you will receive instructions on how to supply
additional information.
Can I request copies of information relevant to
my claim? Yes, you may request copies (free of
charge) by contacting us at [insert contact
information].
What happens next? If you request an external
review, an independent organization will review our
decision and provide you with a written
determination. If this organization decides to
overturn our decision, we will provide coverage or
payment for your health care item or service.
Other resources to help you: For questions about
your rights, this notice, or for assistance, you can
contact: [if coverage is group health plan coverage,
insert: the Employee Benefits Security
Administration at 1-866-444-EBSA (3272)]
[and/or] [if coverage is insured, insert State
Department of Insurance contact information].
[Insert, if applicable in your state: Additionally, a
consumer assistance program can help you file your
appeal. Contact:[insert contact information].]
NAME OF PERSON FILING REQUEST FOR EXTERNAL REVIEW: _________________________
Circle one: Covered person Patient Authorized Representative
Contact information of person filing request for external review (if different from patient)
Address: _________________ Daytime phone:________________ Email:_______________
If person filing request for external review is other than patient, patient must indicate authorization by
signing here: _______________________________________________
Are you requesting an urgent review? Yes No
Briefly describe why you disagree with this decision (you may attach additional information, such as a
physician’s letter, bills, medical records, or other documents to support your claim):
______________________________________________________________________________
______________________________________________________________________________
Send this form and your denial notice to: [Insert name and contact information]
Be certain to keep copies of this form, your denial notice, and all documents and correspondence related
to this claim.
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