A grwy folder with white documents with a red tab at the bottom. Presumably, this is a used for one or many External Utilization ReviewsAn External Review is a review of a medical case conducted by a Physician Advisor who is responsible for reviewing care provided by the primary physician, but is not a member of the physicians’ healthcare organization, and is unaffiliated with the primary care organization. Are you familiar with the term External Utilization Reviews?


External Reviews, also called External Utilization Reviews serve as a final level of patient protection in coverage disputes, and have been mandated by the Patient Protection and Affordability Care Act. Let’s discuss External Utilization Reviews in a bit more detail…

If a patient has received care from a medical professional, and that care has been denied an appeal process will ensue.  If a patient has exhausted the appropriate appeal channels through their health insurance provider, they are guaranteed the right, by federal law, to request that an External Review of their case be conducted by an Independent Review Organization.  Determinations made during the External Review process are final and legally binding.

When Are External Utilization Reviews Most Useful?

External reviews are most useful in scenarios where an unbiased, third-party evaluation of medical services is crucial. These reviews excel in situations where objectivity and impartiality are paramount, such as insurance claims, disputes, or quality assessments. When there’s a need to assess the appropriateness and efficiency of healthcare utilization, external reviews provide an external perspective, ensuring fairness and accuracy.

Furthermore, external utilization reviews are particularly beneficial during complex medical cases or when dealing with specialized treatments. The involvement of external experts ensures a comprehensive evaluation, drawing on a broader range of knowledge and experience. This is especially valuable when internal assessments are limited by organizational biases or lack of specialized expertise.

Timeliness is another factor that makes external utilization reviews highly useful. In situations where quick decisions are essential, external reviews can expedite the evaluation process, providing timely insights that can influence critical healthcare decisions.

Ultimately, these types of reviews shine when there’s a need for transparency, credibility, and an independent assessment of healthcare utilization, making them a valuable tool in ensuring the efficiency and appropriateness of medical services.

When External Reviews Can Benefit You

  1. If you have been denied Medical Coverage for a specific type of treatment that your physician believes is medically necessary
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    and appropriate

  2. If you have already pursued the appropriate channels of appeals through your health insurance provider
  3. If your health insurance provider has still denied coverage and you want to appeal to an outside independent organization for care approval