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

Childhood Cancer Lantern
Search Saved

Ohio program

An independent review of an insurance denial

Ohio external review lets an independent reviewer examine a qualifying health-plan denial.

What it is

Ohio external review lets an independent reviewer examine a qualifying health-plan denial.

A final refusal from the insurer is not always the last word. On an Ohio-issued plan, an independent reviewer decides. A plan where the employer pays its own claims uses a federal route instead; the denial letter names which.

Eligibility rules
  • Ohio-issued fully insured and Marketplace plans fall within ORC Chapter 3922's plan definitions.
  • Private-employer ERISA self-funded plans generally use federal review. Public plans and specified multiple-employer arrangements require their own jurisdiction check; self-funded alone does not settle it.
  • Private-employer ERISA self-funded plans generally use federal review, but self-funded public plans and specified multiple-employer arrangements may be within Ohio's law. For a state-employee, STRS or other public plan, the administrator must identify the applicable procedure; the funding answer alone does not settle it. Internal appeal is normally required, with exceptions for a waived or defective process and qualifying urgent situations. The denial letter and the social worker can help identify the route.
What you get
  • An independent decision in 30 days, or 72 hours for an expedited review.
  • Ohio Department of Insurance help understanding the review route.
What this covers
  • Medical disputes normally go to an independent reviewer. The Department of Insurance has a role in the statutory contractual-review route. Neither route guarantees approval of every disputed service.
If you decide to apply
  1. Ask the clinic or social worker to help you read the denial letter and identify the review process.
  2. If you choose external review, the social worker can help send the request to the plan within its deadline. Qualifying urgent requests can be oral.
  3. Ask the oncologist for a letter explaining medical need and urgency, and keep copies of the request.

Ohio Department of Insurance: 800-686-1526 · Official page ↗

After you apply
  • The reviewer gives a written decision within the applicable 30-day or 72-hour period.
Good to know

The request goes to the plan, which has to hand it to an independent reviewer. The Department of Insurance can help if the plan drags its feet.

Other details
  • The state-employee, STRS or other public plan administrator can confirm the current handbook and external-review procedure. The plan's funding type alone does not settle the route.
  • The final denial should give the issuer's external-review request form or submission method. If you decide to pursue review, the social worker can help send the request through that route, include permission for a representative and keep proof of receipt. Qualifying urgent requests may be made orally. Do not let a general complaint replace or delay the review request.
Official sources
Ask your social worker

“If our plan denies care, would an outside review help, and which route and deadline would apply? Could the clinic help us prepare it if it is worth pursuing?”

Why I’m asking: I want to understand how to challenge a denial that affects my child's treatment.

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 plan within 180 days, ask for urgent review if it is urgent, and keep the denial letter.

Your social worker

The social worker or clinic writes the letter saying why the care is medically needed.

The care team

The oncologist's letter says why the service is medically needed and urgent.

Who decides
An independent review organization decides. The Ohio Department of Insurance oversees the process.
Ask your social worker
“The plan denied this. Can the clinic write the medical-need letter this week, so we can ask for Ohio external review, urgent, within the 180 days?”

How to apply

First step: Write to the plan asking for external review (urgent, if it is) within 180 days of the final denial. Call the Ohio Department of Insurance at 800-686-1526 for help.

  1. Ask for expedited review in the same letter if treatment is waiting.

Official application / program page ↗

Where it starts: Send the written request to the plan within 180 days of the final denial; call the Department of Insurance at 800-686-1526 for help (a request form URL was NOT FOUND)

What to gather

  • The final denial letter
  • The oncologist's letter saying why the care is medically needed
  • Plan ID and the plan's appeals address

How long: 30 days; 72 hours if urgent.

Clock: Request Ohio external review in writing within 180 days of the final denial.

What a yes looks like

The reviewer's written decision overturning the denial. The plan must pay.

What a no looks like, and the next move

Ask the Department of Insurance about a complaint. Ask the social worker about Medicaid (Healthchek) as a second payer.

Watch out

  • 180 days from the final denial. Write the date down.
  • The request goes to the plan in writing. The state helps, but does not receive it.
  • State-employee and teacher plans: ask which review process the denial letter names.
  • The state-employee, STRS or other public plan administrator can confirm the current handbook and external-review procedure. The plan's funding type alone does not settle the route.

If they say no, quote this: Ohio Revised Code Chapter 3922 (external review): 180 days to request, 30 days to decide, 72 hours if expedited.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Independent review of a denial. Ask within 180 days; decision in 30 days, or 72 hours if urgent.

  • $180 — Days to request external review after the final denial
  • $30 — Standard independent review decision
  • $72 — Expedited independent review decision

Legal protection: Written external review request to the health plan issuer within 180 days · Independent review organization decision within 30 days (72 hours expedited)

What it costs the family: None.

The eligibility facts, as published

Plans
health benefit plans and health plan issuers under ORC 3922.01 (Ohio-issued fully insured and Marketplace plans)
Self funded
Private-employer ERISA self-funded plans generally use federal review. Public plans and specified multiple-employer arrangements require their own jurisdiction check; self-funded alone does not settle it.
Public plans
state-employee and teacher plan applicability NOT FOUND

Decisions this site cannot make: Independent review organization decision

Expect friction on: Written request to the issuer

The trap: The request goes to the plan in writing, not to the state. Whether Ohio's process also covers a state-employee or teacher plan was not found; ask the plan which process its denial letter names.

Where I read this

← Back to your options