In some states reviews are performed by physicians or providers who are experts in the treatment of the enrollee's conditions. Other state laws preclude members of independent review boards from having been involved in the initial denial of care or from having a direct financial interest in the outcome of the review. Some states require the Director of Insurance to compile a list of independent review entities. Others require that a member of the health plan sit on the review board. Another factor that varies from state to state is whether or not the reviewer's decision is binding for the plan or the consumer, binding for both, or not binding at all.
Most states specify that decisions made by external reviewers are binding on the health plan.
A few states make the decision binding for both the plan and the consumer. In New Jersey the decisions are not binding at all. Some states require that requests for independent external reviews be made within a certain time period after the initial adverse decision. These time periods range from a low of 15 days after a consumer exhausts the plan's internal grievance system, to a high of two years. Several states impose no time limits on consumers to file a request for an independent external review.