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 and ERISA (for grandfathered plans), external review must be available for 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.