Insurance appeal guide
Prior authorization, appeals and external review
These terms describe different stages. Knowing the stage helps identify the correct recipient, records and deadline for your request.
Prior authorization: a decision before care
A health plan may require approval before certain services, treatments or prescriptions. This is often called prior authorization, preauthorization or precertification. Approval is not necessarily a promise of final payment; other plan requirements may still apply.
If a request is denied, first identify the reason and the reconsideration or appeal instructions. The treating practice may be able to supply missing information or discuss the medical rationale with the plan. Do not assume such a discussion replaces a formal appeal or changes its deadline.
Internal appeal: asking the plan to reconsider
An internal appeal follows the health plan’s process for reviewing its adverse decision. Organize the denial, relevant medical records and any supporting explanation around the reasons given. A post-service claim denial can also have an appeal process.
Use the destination and required format in the notice. Keep a copy of the appeal and proof of submission. The available levels and timing vary with the plan and circumstances; avoid relying on a general online deadline as a substitute for your own notice.
External review: an independent determination
When available, external review takes the dispute to a reviewer outside the health plan’s internal appeal process. Medical-judgment and experimental/investigational disputes are among the issues that may qualify. The applicable process depends on plan type and governing requirements.
EUC can prepare medical materials for an eligible external review within an agreed engagement. On the patient side, EUC is helping prepare the submission; it is not the independent organization deciding that patient’s dispute. Conflicts are screened before EUC accepts work.
The EUC preparation fee is separate from any cost of requesting the external review itself. Check the notice and official instructions before paying anyone or assuming paid consulting is necessary.
Urgency and responsibility
If waiting could affect your health, contact your treating clinician and plan promptly about the applicable urgent process. EUC assesses expedited availability individually. An intake submission does not stop the clock, establish an engagement or confirm EUC will file an appeal.
Until EUC confirms responsibility for a specific submission in writing, follow the denial notice and plan instructions yourself. Medical emergencies require emergency clinical services.
Primary sources and service fit
For Illinois-specific questions, see external review, plan type and official forms.
Published by Expert Urology Consulting · October 5, 2026. Educational information, not individualized medical or legal advice. References are linked above; follow your plan’s own instructions.