Skip to main content
SCC Banner Image
 |   |   |   |     Tyler Building
Skip Navigation LinksSCC Home > Bureau of Insurance > Consumer > External Review
Bureau of Insurance

Independent External Review

Do I qualify for an Independent External Review?

What types of coverage are not eligible for an Independent External Review?

How does an Independent External Review work?

 

Forms for Consumers
External Review Request Form – Form 216-A (doc)
External Review Request Form – Form 216-A (pdf)

Appointment of Authorized Representative – Form 216-B (doc)
Appointment of Authorized Representative – Form 216-B (pdf)

Physician Certification for Expedited External Review Request – Form 216-C (doc)
Physician Certification for Expedited External Review Request – Form 216-C (pdf)

Physician Certification Experimental or Investigational Denials – Form 216-D (doc)
Physician Certification Experimental or Investigational Denials – Form 216-D (pdf)

Forms for Independent Review Organizations:

Independent Review Organization Application – Form 216-E (doc)
Independent Review Organization Application – Form 216-E (pdf)

Independent Review Organization External Review Annual Report – Form 216-G (doc)
Independent Review Organization External Review Annual Report – Form 216-G (pdf)

Form for Health Carriers:

Health Carrier External Review Annual Report – Form 216-F (doc)
Health Carrier External Review Annual Report – Form 216-F (pdf)

Form for Self-insured ERISA Plans:

Self-insured Plan Opt-in for External Review – Form 216-H (doc)
Self-insured Plan Opt-in for External Review – Form 216-H (pdf)