External Review / IRO

External review is the right to have a denial reviewed by an independent review organization (IRO) that has no financial relationship with the payer. Under the ACA, non-grandfathered health plans must offer access to external review of adverse benefit determinations. The IRO's decision is binding on the plan. Most states have their own external review laws; for self-funded ERISA plans, the federal external review process under the ACA applies.