Last updated: July 7, 2026
Internal Appeal vs External Review: What's the Difference?
When your insurance claim is denied, you have two levels of recourse. Understanding the difference — and when to use each — is critical.
Internal Appeal (Your First Step)
What It Is
An internal appeal is a formal request to your insurance company to reconsider a denied claim. You submit a written appeal explaining why the denial was wrong, along with supporting documentation.
Who Reviews It
Your insurer's own appeals team — typically a different reviewer or medical director than the one who made the original denial decision. The ACA requires that the appeal be reviewed by someone who was not involved in the initial denial.
How Long It Takes
For standard pre-service claims, insurers must respond within 30 days. For post-service claims (services already received), the timeline is 60 days. Urgent appeals require a response within 72 hours. For full timeline details, see our appeal response timeline guide.
Need help writing your internal appeal? See our step-by-step guide.
External Review (Your Second Step)
What It Is
An external review is a review of your denied claim by an independent third party — not your insurance company. This is a separate organization with no financial relationship to your insurer.
Who Reviews It
An Independent Review Organization (IRO) — a panel of medical professionals who are not affiliated with your insurer. They review your medical records, the denial, and your appeal independently.
When You're Eligible
You're generally eligible for external review after your internal appeal has been denied, or in some cases, you may be able to request both simultaneously. The HealthCare.gov external review page outlines the full eligibility requirements.
State variation note:Some states have particularly robust external review processes. For example, California's Department of Managed Health Care (DMHC) offers an Independent Medical Review (IMR) process that is considered one of the strongest patient protections in the country.
Comparison Table
| Internal Appeal | External Review | |
|---|---|---|
| Reviewed by | Your insurer's appeals team | Independent third-party organization |
| Timeline | 30–60 days (72 hrs urgent) | 45 days standard, 72 hrs urgent |
| Cost to you | Free | Free |
| Final? | No — can escalate to external review | Usually final and binding on insurer |
| When to use | Always — this is your required first step | After internal appeal is denied |
Do You Need Both?
In most cases, yes — you must complete the internal appeal first before you're eligible for external review. The internal appeal is your required first step. If the internal appeal is denied, external review becomes available as your next level of recourse.
There are exceptions: if your insurer fails to follow proper procedures or misses response deadlines, you may be able to skip directly to external review.
We Help With the Internal Appeal Step
ApproveIt generates professional internal appeal letters citing the exact clinical guidelines your insurer uses. External review requests use similar documentation — ask us about external review letter support too.