Get External Review Request Form - Illinois Department Of Insurance - Insurance Illinois

Filling out the External Review Request Form is an important step for users seeking an independent review of a denied insurance claim. This guide provides clear instructions on how to complete the form accurately and efficiently.

Follow the steps to successfully complete your external review request.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering your personal information in the Applicant section. This includes your first name, last name, address, city, state, zip, daytime phone, and email address.
3. Indicate your relationship to the patient by checking the appropriate box. Options include enrollee/patient, parent of minor child under 18, health care provider, or legal or authorized representative (valid authorization required).
4. Fill out the Covered Person/Patient section with the individual's details for whom medical care was denied, including their first name, last name, address, city, state, zip, daytime phone.
5. In the Insurance Information section, provide details about the health carrier, subscriber's name, subscriber ID, and dependent insurance ID. Specify whether the coverage is through an individual plan or a group plan and provide the necessary names.
6. Complete the Health Care Provider section, entering the treating provider's name, address, contact person, email, and phone number.
7. In the Reason for Appeal section, provide the type and dates of services being denied while attaching any pertinent documentation. Include the adverse or final adverse determination date.
8. Gather required attachments before submitting the form, including a copy of the patient’s insurance ID card, the final denial letter from the health carrier, and any applicable authorization if represented.
9. If applicable, complete the Physician Certification form for expedited or experimental/investigational review. Check the relevant options for expedited review or review of investigational denials.
10. Sign and date the applicant signature section and, if necessary, have the parent sign if the covered person/patient is under 18 years old.
11. Make sure to submit this request and all supporting documents to the correct address, following the provided filing deadline of four months from the final denial letter.
12. Review and save changes, or choose to download, print, or share the form as needed.

Submit your External Review Request Form online today to ensure your appeal is processed in a timely manner.