The external review process has your case reviewed by a third party unaffiliated with your insurer. The external review process is purely a document review process; once the independent review organization has reviewed your case, it will issue a final case synopsis letter detailing the outcome of your case.
This report details prior external review cases for which a final determination has been made. It is updated every quarter (March, June, September, December) with decisions by Independent Review Organizations (IROs). This report contains information on a rolling four-year basis.
The report can be downloaded in Excel format here.
Please note that every external review case is unique and an overturn for one case does not guarantee an overturn for another. Information on this page is for historical informational purposes only. The Division of Financial Regulation cannot provide guidance on specific cases and outcomes of pending/potential cases or cases currently under review.
“Cases Where Full Review Was Completed" in the General External Review Yearly Statistics table (below) only includes case outcomes of “Overturned Denial," “Partial Overturn," or “Upheld Denial." Other case outcomes (found in the full report) include “Ineligible," “Administrative Overturn," “Insurer Overturn," and “Withdrawn".
| General External Review Yearly Statistics |
|---|
| Year | Cases Received
| Cases Where Full Review Was Completed | Other Case Outcomes |
|---|
| Cases Reviewed | Insurer Denial Overturned or Partially Overturned | Insurer Denial Upheld | Cases Ineligible | Cases Overturned by Insurer or Administrative Overturn | Cases Withdrawn |
|---|
| 2019 | 411 | 268 | 91 | 34% | 177 | 66% | 112 | 25 | 6 |
| 2020 | 367 | 273 | 96 | 35% | 177 | 65% | 79 | 12 | 3 |
| 2021 | 326 | 241 | 76 | 32% | 165 | 68% | 61 | 16 | 8 |
| 2022 | 498 | 354 | 131 | 37% | 223 | 63% | 110 | 18 | 16 |
2023
| 499
| 352
| 128
| 36% | 224
| 64% | 115
| 8 | 24 |
*2023 data up-to-date through December 31, 2023
|
In rare instances, a case may need to be reassigned to a different IRO than the one to which it was initially assigned. Case numbers that were ultimately reassigned are not included in the list of Cases Reviewed.
Redacted Synopsis Reports are available to the public upon request. Please send an email with requested case numbers to
Exreview.Ins@dcbs.oregon.gov
Information contained in the report includes:
- External Review Case Number
- Date Division Received External Review Request from Insurer
- Insurer
- Type of External Review Requested
- IRO Company
- Decision Date
- Case Outcome
- Case Category
- Full Procedure/Service/Treatment Name
Detailed explanations of each column can be found on the “Field Definitions" tab of the Excel spreadsheet.