Written by a parent, not a doctor. Nothing here is medical advice.

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Louisiana program

An independent review of an insurance denial

Louisiana external review lets an independent reviewer assess certain denials from a state-regulated health plan.

What it is

Louisiana external review lets an independent reviewer assess certain denials from a state-regulated health plan.

A final refusal from the insurer is not always the last word. On a plan Louisiana regulates, an independent reviewer decides after the plan's own appeal. A plan where the employer pays its own claims uses a federal route instead. The oncology team's letter is what makes a case urgent.

Eligibility rules
  • This state route covers issuers under Louisiana insurance law or the insurance commissioner’s jurisdiction.
  • Self-funded ERISA plans, limited-benefit plans, short-term plans and workers’ compensation are excluded.
What you get
  • No-cost review outside the health plan for eligible denials.
  • An urgent decision within 72 hours, or sooner when the child’s condition requires it.
What the help covers
  • The independent review decision can overturn the insurer’s refusal and binds the insurer.
If you decide to apply
  1. Ask the hospital social worker to go through the denial notice and internal appeal result.
  2. Have the plan document and the oncologist’s medical-necessity letter ready.
  3. If you choose external review, send the written request to the insurer using the denial notice’s instructions.

An independent review organization assigned after the request reaches the insurer: 800-259-5300 · Official page ↗

After you apply
  • The social worker can help preserve the notice-receipt date and check whether internal appeal requirements are complete or an exception applies. One exhaustion exception addresses an internal review unresolved after 30 days without an agreed extension, excluding retrospective claims. Qualifying urgent cases can use expedited internal and external review together; retrospective claims cannot use urgent external review.
  • The request window is four calendar months after receipt of the applicable adverse or final adverse notice, not 120 days. Standard insurer eligibility review and notices are due within five business days; the commissioner’s notice or assignment follows within one business day of the relevant insurer notice. Standard decisions are due within 45 days after the insurer receives the request. Urgent eligibility handling is immediate; a qualifying urgent decision is due within 72 hours of insurer receipt, with written confirmation within 48 hours of an oral decision.
Good to know

The four-month clock runs from receipt of the adverse or final adverse decision. The internal appeal usually comes first.

Other details
  • The Department of Insurance can help identify the route at 800-259-5300. Self-funded plans have a separate federal appeal route.
Official sources
Ask your social worker

“If we receive a denial, could an outside review help? Could you explain the timing and limits and help with the request if it is the right next step?”

Why I’m asking: I want to understand how treatment refusals can be reviewed without losing time.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Send the written request to the insurer within four months and ask for the expedited route if treatment cannot wait.

Your social worker

The oncologist writes why a delay would harm the child.

The care team

The treating doctor supports the expedited request in writing.

Who decides
An independent review organisation, not the plan.
Ask the care team
“Can you write that a delay would harm my child, so we can ask for the expedited outside review of this denial?”

How to apply

First step: Keep the denial notice, diarise four months from its date, and ask the oncologist for a letter about delay.

  1. Keep the denial notice and diarise four months from the date on it.
  2. Ask the oncologist for a letter saying why delay would harm your child, and ask for the expedited route.
  3. Call the Department of Insurance on 800-259-5300 if the plan will not tell you how to file.

Official application / program page ↗

Where it starts: Send the written request to the insurer, following the instructions on the denial notice.

What to gather

  • The denial notice and any internal appeal decision
  • The doctor's letter of medical necessity
  • The policy or plan document

How long: 45 days for an ordinary decision, no more than 72 hours when urgent.

What a yes looks like

A written decision from the reviewer overturning the plan, which the plan has to follow.

What a no looks like, and the next move

If you are told the plan is self-funded, ask for that in writing and use the plan's federal appeal instead.

Watch out

  • Self-funded employer plans are outside this route. Ask the benefits office which kind yours is.
  • The internal appeal usually has to happen first; the denial notice says how.
  • Ask for the expedited route in writing when treatment cannot wait.

If they say no, quote this: R.S. 22:2436: within four months of the adverse determination a covered person may request external review, whatever the claim amount, and the reviewer decides within 45 days.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

An independent review outside the plan: four months to file, 45 days to decide, and no more than 72 hours when it is urgent.

  • $4 — Months to file after the denial notice
  • $45 — Days for an ordinary decision
  • $72 — Hours for an urgent decision

Legal protection: An independent review organisation outside the plan decides · Four months to file from the date the denial notice is received · No more than 72 hours for an expedited review, and sooner if the child's condition needs it

What it costs the family: None.

The eligibility facts, as published

Plans
issuers subject to Louisiana insurance law or the commissioner's jurisdiction
Excluded
self-funded ERISA plans, limited-benefit plans, short-term plans and workers' compensation
Deadline
four months after receiving the adverse or final adverse determination
Statute refs
R.S. 22:2393, 22:2434, 22:2436, 22:2437

The trap: The clock is four months from the notice, but the internal appeal usually has to happen first. Read the denial notice for its instructions, and ask for the expedited route in writing when treatment cannot wait.

Where I read this

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