External Review Process

Depending on the plan in which you participate, you may be entitled to an external review by an Independent Review Organization. Please refer to your SPD to determine whether external review is available under your benefit plan and for more information on the external review process.

In order to qualify for an external review, the following requirements must have been met:

  • You have exhausted the plan’s internal appeal process (which includes the First Level Appeal and Second Level Appeal)  
  • You are or were covered under the plan at the time the health care item or service was requested or, in the case of a retrospective review, were covered under the plan at the time the health care item or service was provided 
  • The adverse benefit determination or the final adverse benefit determination does not relate to your failure to meet the requirements for eligibility under the terms of the group health plan (e.g., worker classification or similar determination) 
  • You have provided all the information and forms required to process an external review 
  • NOTE: Must be filed within 4 (four) months from the date of the Second Level Appeal Denial Letter

In addition, one or more of the following must apply for your claim to be eligible for external review:

  • The claim is regarding prescription drugs that involve medical judgment 
  • The claim involves rescissions of coverage (regardless of whether any particular benefit is affected) 

To request an external review:

  • Complete the external review request form 
  • Fax the form to 309-285-8296
  • If you do not have access to a fax machine, mail the form to: 
          Prescription Drug – Claims Benefit Review
          100 N E Adams St – AB4400
          Peoria IL 61629-4400