Which statement describes an external appeal?

• A. An external appeal is a review by a state insurance commission's staff only.
• B. An external appeal is a review by a plan's clinical team.
• C. An external appeal is a review by a consumer advocate group.
• D. An external appeal is a review by an independent entity/state agency.

Answer: (D)

An external appeal is a review conducted by an entity that is independent of the insurance plan, typically an independent review organization or a state agency. The goal is to re-evaluate a denial or coverage decision using objective medical standards, ensuring a fair check against the plan’s own internal processes. This independence from the plan is what sets an external appeal apart from reviews done inside the plan.

The other options describe reviews that remain under the plan’s control or advocacy groups, rather than a neutral, external reviewer. A state insurance commission’s staff or the plan’s clinical team are part of the insurer’s own decision-making process, not independent reviewers. A consumer advocate group may support the patient, but they do not perform the formal external review.