be understood by the participant, beneficiary, or en-
rollee and shall include— 
(A) the specific reasons for the determina-
tion (including a summary of the clinical or sci-
entific evidence used in making the determina-
tion); 
(B) the procedures for obtaining additional 
information concerning the determination; and 
(C) notification of the right to an inde-
pendent external review under section 104 and 
instructions on how to initiate such a review. 
SEC. 104. INDEPENDENT EXTERNAL APPEALS PROCE-
DURES. 
(a) RIGHT TO EXTERNAL APPEAL.—A group health 
plan, and a health insurance issuer offering health insur-
ance coverage, shall provide in accordance with this sec-
tion participants, beneficiaries, and enrollees (or author-
ized representatives) with access to an independent exter-
nal review for any denial of a claim for benefits. 
(b) INITIATION OF THE INDEPENDENT EXTERNAL 
REVIEW PROCESS.— 
(1) TIME
TO
FILE.—A request for an inde-
pendent external review under this section shall be 
filed with the plan or issuer not later than 180 days 
after the date on which the participant, beneficiary,
or enrollee receives notice of the denial under section 
103(d) or notice of waiver of internal review under 
section 103(a)(4) or the date on which the plan or 
issuer has failed to make a timely decision under 
section 103(d)(2) and notifies the participant or 
beneficiary that it has failed to make a timely deci-
sion and that the beneficiary must file an appeal 
with an external review entity within 180 days if the 
participant or beneficiary desires to file such an ap-
peal. 
(2) FILING OF REQUEST.— 
(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, a group 
health plan, or health insurance issuer offering 
health insurance coverage, may— 
(i) except as provided in subparagraph 
(B)(i), require that a request for review be 
in writing; 
(ii) limit the filing of such a request 
to the participant, beneficiary, or enrollee 
involved (or an authorized representative); 
(iii) except if waived by the plan or 
issuer under section 103(a)(4), condition 
access to an independent external review 
under this section upon a final determina-
tion of a denial of a claim for benefits 
under the internal review procedure under 
section 103; 
(iv) except as provided in subpara-
graph (B)(ii), require payment of a filing 
fee to the plan or issuer of a sum that does 
not exceed $25; and 
(v) require that a request for review 
include the consent of the participant, ben-
eficiary, or enrollee (or authorized rep-
resentative) for the release of necessary 
medical information or records of the par-
ticipant, beneficiary, or enrollee to the 
qualified external review entity only for 
purposes of conducting external review ac-
tivities. 
(B) REQUIREMENTS AND EXCEPTION RE-
LATING TO GENERAL RULE.— 
(i) ORAL
REQUESTS
PERMITTED
IN 
EXPEDITED OR CONCURRENT CASES.—In 
the case of an expedited or concurrent ex-
ternal review as provided for under sub-
section (e), the request for such review 
may be made orally. A group health plan, 
or health insurance issuer offering health
insurance coverage, may require that the 
participant, beneficiary, or enrollee (or au-
thorized representative) provide written 
confirmation of such request in a timely 
manner on a form provided by the plan or 
issuer. Such written confirmation shall be 
treated as a consent for purposes of sub-
paragraph (A)(v). In the case of such an 
oral request for such a review, the making 
of the request (and the timing of such re-
quest) shall be treated as the making at 
that time of a request for such a review 
without regard to whether and when a 
written confirmation of such request is 
made. 
(ii) EXCEPTION TO FILING FEE RE-
QUIREMENT.— 
(I) INDIGENCY.—Payment of a 
filing fee shall not be required under 
subparagraph (A)(iv) where there is a 
certification (in a form and manner 
specified in guidelines established by 
the appropriate Secretary) that the 
participant, beneficiary, or enrollee is
indigent (as defined in such guide-
lines). 
(II) FEE NOT REQUIRED.—Pay-
ment of a filing fee shall not be re-
quired under subparagraph (A)(iv) if 
the plan or issuer waives the internal 
appeals 
process 
under 
section 
103(a)(4). 
(III) REFUNDING OF FEE.—The 
filing fee paid under subparagraph 
(A)(iv) shall be refunded if the deter-
mination under the independent exter-
nal review is to reverse or modify the 
denial which is the subject of the re-
view. 
(IV) COLLECTION
OF
FILING 
FEE.—The failure to pay such a filing 
fee shall not prevent the consideration 
of a request for review but, subject to 
the preceding provisions of this clause, 
shall constitute a legal liability to pay. 
(c) REFERRAL TO QUALIFIED EXTERNAL REVIEW 
ENTITY UPON REQUEST.— 
(1) IN GENERAL.—Upon the filing of a request 
for independent external review with the group
health plan, or health insurance issuer offering 
health insurance coverage, the plan or issuer shall 
immediately refer such request, and forward the 
plan or issuer’s initial decision (including the infor-
mation described in section 103(d)(3)(A)), to a 
qualified external review entity selected in accord-
ance with this section. 
(2) ACCESS TO PLAN OR ISSUER AND HEALTH 
PROFESSIONAL INFORMATION.—With respect to an 
independent external review conducted under this 
section, the participant, beneficiary, or enrollee (or 
authorized representative), the plan or issuer, and 
the treating health care professional (if any) shall 
provide the external review entity with information 
that is necessary to conduct a review under this sec-
tion, as determined and requested by the entity. 
Such information shall be provided not later than 5 
days after the date on which the request for infor-
mation is received, or, in a case described in clause 
(ii) or (iii) of subsection (e)(1)(A), by such earlier 
time as may be necessary to comply with the appli-
cable timeline under such clause. 
(3) SCREENING OF REQUESTS BY QUALIFIED 
EXTERNAL REVIEW ENTITIES.—
(A) IN GENERAL.—With respect to a re-
quest referred to a qualified external review en-
tity under paragraph (1) relating to a denial of 
a claim for benefits, the entity shall refer such 
request for the conduct of an independent med-
ical review unless the entity determines that— 
(i) any of the conditions described in 
clauses (ii) or (iii) of subsection (b)(2)(A) 
have not been met; 
(ii) the denial of the claim for benefits 
does not involve a medically reviewable de-
cision under subsection (d)(2); 
(iii) the denial of the claim for bene-
fits relates to a decision regarding whether 
an individual is a participant, beneficiary, 
or enrollee who is enrolled under the terms 
and conditions of the plan or coverage (in-
cluding the applicability of any waiting pe-
riod under the plan or coverage); or 
(iv) the denial of the claim for bene-
fits is a decision as to the application of 
cost-sharing requirements or the applica-
tion of a specific exclusion or express limi-
tation on the amount, duration, or scope of 
coverage of items or services under the
terms and conditions of the plan or cov-
erage unless the decision is a denial de-
scribed in subsection (d)(2). 
Upon making a determination that any of 
clauses (i) through (iv) applies with respect to 
the request, the entity shall determine that the 
denial of a claim for benefits involved is not eli-
gible for independent medical review under sub-
section (d), and shall provide notice in accord-
ance with subparagraph (C). 
(B) PROCESS
FOR
MAKING
DETERMINA-
TIONS.— 
(i) NO DEFERENCE TO PRIOR DETER-
MINATIONS.—In 
making 
determinations 
under subparagraph (A), there shall be no 
deference given to determinations made by 
the plan or issuer or the recommendation 
of a treating health care professional (if 
any). 
(ii) 
USE
OF
APPROPRIATE
PER-
SONNEL.—A qualified external review enti-
ty shall use appropriately qualified per-
sonnel to make determinations under this 
section.
(C) NOTICES
AND
GENERAL
TIMELINES 
FOR DETERMINATION.— 
(i) NOTICE IN CASE OF DENIAL OF 
REFERRAL.—If the entity under this para-
graph does not make a referral to an inde-
pendent medical reviewer, the entity shall 
provide notice to the plan or issuer, the 
participant, beneficiary, or enrollee (or au-
thorized representative) filing the request, 
and the treating health care professional 
(if any) that the denial is not subject to 
independent medical review. Such notice— 
(I) shall be written (and, in addi-
tion, may be provided orally) in a 
manner calculated to be understood 
by a participant or enrollee; 
(II) shall include the reasons for 
the determination; 
(III) include any relevant terms 
and conditions of the plan or cov-
erage; and 
(IV) include a description of any 
further recourse available to the indi-
vidual.
(ii) GENERAL TIMELINE FOR DETER-
MINATIONS.—Upon receipt of information 
under paragraph (2), the qualified external 
review entity, and if required the inde-
pendent medical reviewer, shall make a de-
termination within the overall timeline that 
is applicable to the case under review as 
described in subsection (e), except that if 
the entity determines that a referral to an 
independent medical reviewer is not re-
quired, the entity shall provide notice of 
such determination to the participant, ben-
eficiary, or enrollee (or authorized rep-
resentative) within such timeline and with-
in 2 days of the date of such determina-
tion. 
(d) INDEPENDENT MEDICAL REVIEW.— 
(1) IN GENERAL.—If a qualified external review 
entity determines under subsection (c) that a denial 
of a claim for benefits is eligible for independent 
medical review, the entity shall refer the denial in-
volved to an independent medical reviewer for the 
conduct of an independent medical review under this 
subsection.
(2) MEDICALLY
REVIEWABLE
DECISIONS.—A 
denial of a claim for benefits is eligible for inde-
pendent medical review if the benefit for the item or 
service for which the claim is made would be a cov-
ered benefit under the terms and conditions of the 
plan or coverage but for one (or more) of the fol-
lowing determinations: 
(A) DENIALS BASED ON MEDICAL NECES-
SITY AND APPROPRIATENESS.—A determination 
that the item or service is not covered because 
it is not medically necessary and appropriate or 
based on the application of substantially equiva-
lent terms. 
(B) DENIALS
BASED
ON
EXPERIMENTAL 
OR
INVESTIGATIONAL
TREATMENT.—A deter-
mination that the item or service is not covered 
because it is experimental or investigational or 
based on the application of substantially equiva-
lent terms. 
(C) DENIALS OTHERWISE BASED ON AN 
EVALUATION
OF
MEDICAL
FACTS.—A deter-
mination that the item or service or condition 
is not covered based on grounds that require an 
evaluation of the medical facts by a health care 
professional in the specific case involved to de-