External review preparation packet
Patient / representative:
[Patient name or representative name]
Insurance plan or administrator:
[Insurance company / plan / external review administrator]
Denial category to verify:
Medical necessity or appropriateness denial
Current review status:
Final internal appeal denial received
Urgency level:
Standard review preparation
Filing or representative status:
Patient filing personally
Final denial or final determination date:
[Date shown on final denial, final determination, EOB, or appeal decision]
Deadline language from notice:
[Quote the external review deadline and filing instructions from the final denial notice. Do not guess if the notice gives a specific process.]
Service, medication, test, referral, device, or care at issue:
[Identify exactly what was denied or not paid, including authorization or claim numbers if needed.]
Plan's stated denial reason:
[Quote or summarize the plan's reason: medical necessity, investigational, level of care, not covered, out of network, missing information, or other reason.]
Internal appeal history:
[Summarize the internal appeal request, what was submitted, the decision received, and any dates or reference numbers.]
Treating-provider support to request or attach:
[List clinician letter, diagnosis, functional limitations, failed alternatives, risk of delay, treatment rationale, or records that directly address the denial reason.]
Functional impact and urgency facts:
[Explain how the denial affects pain, function, safety, sleep, eating, mobility, ability to work, caregiving, or care continuity. Keep it factual.]
Documents to include or preserve:
[Final denial, EOB, prior authorization notice, internal appeal copy, provider letter, supporting records, call notes, reference numbers, and proof of submission.]
Questions before filing:
[Where should this be filed? Is an authorized representative form needed? Is expedited review available? What proof of submission will be accepted? What is the expected response timeframe?]
Suggested next step:
Prepare a standard external review packet that follows the denial notice, includes copies rather than originals when appropriate, and keeps a submission record.
Privacy and legal boundary:
This browser-only organizer does not file an appeal, store information, decide eligibility for external review, give legal advice, or guarantee coverage. Follow the final denial notice, plan documents, state process, or HHS-administered process if applicable. Keep originals where needed and preserve copies and proof of submission.
Not medical advice, legal advice, emergency help, or a guarantee of external review eligibility or coverage. Nothing is uploaded, saved, or submitted by this browser-only tool.
