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

Navigating the Request For External Review form can be overwhelming, but this guide is designed to help you through each step of the process. Whether you are a patient or a legal representative, the following instructions will provide you with clear guidance to ensure a successful submission.

Follow the steps to complete your external review request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the applicant's information. This includes their first name, last name, address, city, state, daytime phone number, email address, zip code, and fax number. Additionally, select the applicant's relationship to the patient by checking one of the provided boxes.
3. Enter the patient's information, similar to the applicant's. This includes the patient's first name, last name, address, city, state, daytime phone number, email address, and zip code.
4. Provide the insurance information. Include the health carrier name, primary insured's name, primary insured ID, patient ID, and indicate the type of coverage by checking the appropriate box.
5. Complete the health care provider section by providing the treating provider's name, address, contact person's name, email, phone number, and fax number.
6. In the reason for appeal section, describe the type and dates of the service being denied. Ensure to attach any pertinent documentation that supports your case.
7. Provide details about the adverse or final adverse determination date. A copy of this determination must be attached.
8. Include all required items such as a copy of the patient’s insurance identification card, the final denial letter, any valid written authorization for representatives, and, if necessary, additional forms related to expedited reviews.
9. Sign and date the application, ensuring the appropriate representative signs if the applicant is under 18.
10. Review the completed form for accuracy, ensuring all necessary documentation is attached. After confirming all details are correct, users can save changes, download, print, or share the form as needed.

Complete your Request For External Review online today to ensure timely processing of your appeal.