What does "external review" mean in health insurance?

The term "external review" in health insurance refers to a process wherein an outside entity evaluates a payer's decision on a denied claim. This procedure allows insured individuals to have an impartial assessment of their claims, especially when an insurance company has denied coverage for a particular treatment or service.

When a claim is denied, the policyholder typically has the right to request an external review, which is conducted by independent reviewers who assess the case based on the evidence and circumstances surrounding the denial. This ensures that a decision is made fairly and independently, adhering to established medical guidelines and the particulars of the insurance policy. This external scrutiny is crucial for policyholders because it provides an additional layer of oversight beyond the internal processes of the insurance company, thus promoting transparency and accountability in claims handling.

The other options presented do not accurately represent the concept of external review. For instance, a reassessment of internal company protocols does not involve external evaluation, and appealing claims directly to insurers pertains more to the internal dispute resolution process rather than an independent review. Lastly, reviewing patient outcomes within a healthcare facility does not connect directly to the insurance claim process, as it focuses on clinical effectiveness rather than the denial of insurance claims.