Which entity reviews an external appeal?

• A. The insurer's internal review board
• B. An independent external review organization
• C. The provider's office
• D. The patient’s employer

Answer: (B)

When an external appeal is filed, the review is handled by an independent external review organization. This entity is separate from the insurer and from the provider, and it brings an impartial, evidence-based assessment to the decision about coverage or medical necessity. The reviewer evaluates the medical records, policy provisions, and standard care guidelines to determine whether the prior denial or limitation was appropriate. This independence helps ensure fairness and reduces potential conflicts of interest in the decision.

The insurer’s internal review board handles its own internal appeals, focusing on the insurer’s policies and processes. The provider’s office or the patient’s employer do not perform this formal external review role, so they aren’t the appropriate bodies to reassess coverage decisions. The independent external review organization provides the final, objective assessment that can sustain or overturn the initial decision based on medical necessity and policy language.