Florida external review
Florida's non-grandfathered individual and fully insured group plans use federal external-review protections. The insurer may elect HHS-administered review or contract with an independent review organization; use the final denial to identify yours. HHS review reopened July 31, 2026, is free, and generally decides within 45 days (72 hours expedited). Medicare, Medicaid, FEHB, TRICARE, and other distinct programs follow their own appeal rules.
Deadlines and decision timelines
- Your filing window: 4 calendar months after receipt of the notice or final determination denying the claim. Confirm eligibility and the filing instructions on your final denial. Four calendar months are not a fixed number of days; this duration alone is not a personal filing deadline. Filing rule verified 2026-10-05.
- Standard review decided in: 45 days from receipt
- Expedited review decided in: 72 hours or less — medical urgency — waiting would jeopardize your life or health
- Cost to you: None under the HHS process (issuer-contracted reviews capped at $25)
How to file, step by step
- Finish your internal appeal. Federal external review generally follows the final internal denial, with exceptions for urgent cases. The filing window is 4 calendar months after receipt of the notice or final determination denying the claim; keep proof of receipt.
- Read your denial letter's external-review instructions. The denial notice names the filing channel. Some issuers elect the HHS-administered process; others contract directly with accredited independent review organizations. Do not assume HHS participation from residence alone.
- If your plan uses HHS review, follow its current filing instructions. HealthCare.gov links to the secure MAXIMUS filing site. It also lists fax (888) 866-6190, email ferp@maximus.com, and mail to MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. Call (888) 866-6205 for the request form and guidance.
- Save your filing proof and check the applicable deadline. Keep your final denial, proof of receipt and submission, and medical evidence. The July 31 CMS notice granted only a limited extension through October 2, 2026 for eligible original deadlines from July 1 through August 3; it does not authorize a new extension after that date.
Who can use it
- Non-grandfathered fully-insured Florida plans, for denials involving medical judgment, experimental/investigational determinations, and rescissions.
- Self-funded employer (ERISA) plans also use the federal route — never a state process — with plan-contracted review organizations under Department of Labor oversight.
What to know
- Florida's DFS Insurance Helpline (1-877-693-5236) is a real human resource for navigating the federal process.
- The insurer is required by law to accept the external reviewer's decision.
- Florida's old Statewide Subscriber Assistance Program statute no longer appears in current Florida Statutes — the federal process is the operative route.
Denial data from plans operating in Florida
| Insurer | Contract / plan | Line | Requests | Denied | Appeals overturned |
|---|---|---|---|---|---|
| Centene | 49004 Ambetter | Marketplace | 419,452 | 21% | 58.23% |
| Centene | H1032 Wellcare | Medicare Advantage | 171,190 | 19.54% | 84.38% |
| Centene | 86382 Ambetter | Marketplace | 6,402 | 18.28% | 64.15% |
| Elevance Health | FL-CHIP Simply | Medicaid | — | 24.5% | 18.6% |
| Molina Healthcare | FL-MARKETPLACE | Marketplace | — | 13% | 50% |
| Elevance Health | FL-Medicaid Simply | Medicaid | — | 12% | 35.7% |
| Florida Blue | H1035 | Medicare Advantage | — | 9% | 55% |
| Florida Blue | H5434 | Medicare Advantage | — | 8% | 56% |
| Florida Blue | 16842 | Marketplace | — | 5% | 28% |
| Florida Blue | 30252 | Marketplace | — | 1% | 30% |
Florida external review FAQ
Why doesn't Florida have its own external review?
CMS lists Florida among the states without an applicable state process meeting ACA external-review standards. Covered individual and group plans may elect HHS review or use an issuer-contracted reviewer; the denial notice identifies which. Medicare, Medicaid and other distinct programs have their own rules.
What's the current status of the federal review process?
CMS reopened the HHS-administered Federal External Review Process on July 31, 2026. Its limited extension gave eligible consumers whose original filing deadline fell July 1–August 3, 2026 until October 2, 2026 to file. That notice does not extend other deadlines or establish a new extension after October 2. The HHS process applies only when the plan elects it; other plans use a contracted independent review organization or a separate program's rules.
Where do I file, and does the 2026 extension still apply?
Use the reviewer identified in your final denial. If the plan uses HHS review, follow HealthCare.gov's current MAXIMUS instructions. The specific 2026 extension ran through October 2 for eligible July 1–August 3 original deadlines. It did not extend every deadline. If you may be late, contact the named reviewer promptly; do not assume a further extension.
How long does federal external review take?
A standard review is decided no later than 45 days from receipt. Expedited reviews for medically urgent cases are decided within 72 hours or less.
Is the decision binding?
Yes — your insurer is required by law to accept the external reviewer's decision.
Primary sources
- CMS — HHS FERP reopening and limited deadline extension (verified 2026-10-05)
- HealthCare.gov — current federal filing instructions (verified 2026-10-05)
- CMS — external appeals (state process list)
- FLOIR — consumer resources