To qualify for an Independent External Review:

1. The patient must be covered by a contract issued in Virginia by a licensed health carrier, or by a self-insured ERISA plan whose plan sponsor’s headquarters is located in Virginia and the plan has elected to use Virginia’s External Review process.
2. You must have exhausted the carrier’s internal appeal process. The process is deemed to be exhausted in the following situations:
   • All available internal appeals have been exhausted.
   • The patient filed an appeal and has not received a response from the carrier on its determination (unless a delay was agreed to) by either 30 days from the date of filing a pre-service appeal, or 60 days from the date of filing a post-service appeal.
   • A request for an expedited internal appeal of an adverse determination has been filed with the health carrier. A simultaneous expedited External Review may be requested.
   • The health carrier has agreed to waive the exhaustion requirement.
3. The adverse determination for an admission, availability of care, continued stay, or other health care services that is a covered benefit has been reviewed by the health carrier or its designated review entity and has been determined to not meet its requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or is determined to be experimental or investigational, and the requested service or payment for the service is therefore denied, reduced or terminated.
4. A complete External Review request must be received by the Bureau of Insurance within 120 days after the date you received notice of your right to an External Review.

The following types of coverage are not eligible for Virginia's process of Independent External Review:

• Policies or certificates that provide coverage only for a specified disease, specified accident or accident-only coverage;
• Credit;
• Disability income;
• Hospital indemnity;
• Long-term care;
• Dental, vision, or any other limited supplemental benefit or a Medicare supplement policy of insurance;
• Plans through Medicare, Medicaid, or the federal employees health benefits program;
• Any coverage issued under Chapter 55 of Title 10 of the U.S. Code (TRICARE), and any coverage issued supplemental to that coverage;
• Any coverage issued as supplemental to liability insurance, workers’ compensation or similar insurance; and
• Automobile medical payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group or individual basis.

Self-insured employee welfare benefit plans may choose to use Virginia’s process for Independent External Review if the plan sponsor’s headquarters is located in Virginia.

When the Bureau receives your appeal, it is sent to the health carrier or self-funded plan contact involved to verify your request’s completeness and eligibility. If any additional information is needed to complete your request or verify eligibility, the health carrier/self-funded plan contact will request from you the specific information needed. A timeframe will be given for you to submit this information. If you do not submit this information to the entity requesting it in a timely manner, your request may be terminated. If your request is determined to be ineligible, you may appeal this determination to the Bureau.

After you have been notified that your request is complete and eligible for this review process, the Bureau will randomly select an Independent Review Organization (IRO) that is not affiliated with your carrier or self-funded plan, and has no conflict of interest with your case to perform the review. For standard External Review requests, once you are notified of the name of the IRO, you will be given 5 business days from your receipt of this notification to submit any additional information you would like reviewed regarding your case. Your health carrier/self-funded plan must also submit all of its documents and information considered in making its determination to the IRO for review. The IRO will issue its determination to the parties involved. The decision is binding on the health carrier/self-funded plan, and on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.

If a request for an expedited External Review is submitted when an expedited internal appeal request has been made, the IRO will make a determination as to whether the internal expedited appeal process must be completed prior to the expedited External Review process beginning.