Georgia external review

Independent review (OCI) / federal external reviewFile within 120 daysFee: None — the managed care entity pays the full costExpedited: 72 hours

Georgia runs two tracks. The state's Patient's Right to Independent Review Act covers managed care denials over $500 — free, decided in 15 business days, with the burden of proof on the insurer. But most ACA-regulated plans in Georgia use the federally administered external review instead, because CMS classifies Georgia's process as not meeting federal ACA standards.

Who to contact

GA Office of Commissioner of Insurance and Safety Fire (OCI)

oci.georgia.gov/file-consumer-insurance-complaint

1-800-656-2298

Authority: O.C.G.A. § 33-20A-30 et seq. (Patient's Right to Independent Review Act)

Deadlines and decision timelines

Your filing window: 120 days from the final internal denial.
Standard review decided in: State track: 15 business days after the record-submission window closes; federal track: 45 days
Expedited review decided in: 72 hours — your treating provider determines that standard timing would jeopardize your health or functional capacity
Cost to you: None — the managed care entity pays the full cost

How to file, step by step

Read your final denial letter first. It states which track applies to your plan — Georgia's state independent review or the federal external review process. The paths and deadlines differ.
State track: send a written request to OCI. No special form is required — a simple written request with your identifying information suffices (Rule 120-2-111). File through OCI's Consumer Complaint Portal or contact Consumer Services at 1-800-656-2298.
Federal track: follow the letter's federal filing instructions. Federal external review is normally filed at externalappeal.cms.gov within 4 months of the final denial. As of July 2026, CMS reports the HHS-administered portal is temporarily unavailable and has said it will provide information about extended deadlines — keep a copy of everything and watch the CMS external appeals page.
The reviewer decides. On the state track the insurer must ship your records to the IRO within 3 business days of assignment, and the IRO decides within 15 business days — 72 hours if expedited.

Who can use it

State track: enrollees of fully-insured managed care plans, where the denied treatment reasonably appears to be a covered benefit and its cost is at least $500.
Most ACA-regulated plans in Georgia use the federal external review process instead — your denial letter says which applies.
Not under OCI jurisdiction: self-insured employer (ERISA) plans, Federal Employees' plans, Medicare, Medicaid, the State of Georgia Employee's Health Plan, and University System of Georgia policies.

What to know

The burden of proof in a Georgia independent review rests with the insurer, not with you (Rule 120-2-111).
A state-track IRO decision in your favor is final and binding on the plan, and relief must be provided without delay (O.C.G.A. § 33-20A-37).
The state track has a $500 minimum treatment cost — smaller claims should use the internal appeal and OCI consumer complaint routes.
Experimental-treatment review has its own stricter track requiring physician certification and peer-reviewed evidence.

Denial data from plans operating in Georgia

Prior-authorization metrics these insurers disclosed for Georgia contracts under the federal CMS-0057-F transparency rule (CY2025, insurer-published). A high denial rate paired with a high appeal-overturn rate is the profile worth appealing. Full methodology: insurer denial rates.

Insurer	Contract / plan	Line	Requests	Denied	Appeals overturned
Centene	H1112 Wellcare	Medicare Advantage	52,573	15.31%	94.19%
Centene	H0111 Wellcare	Medicare Advantage	12,773	15.66%	94.26%
Elevance Health	H5422 Anthem	Medicare Advantage	—	6.5%	77%

Georgia external review FAQ

Which review process applies to my Georgia plan?

It depends on the plan. Georgia's state independent review covers fully-insured managed care plans for denials over $500, but CMS classifies Georgia's process as not meeting federal ACA standards, so most ACA-regulated plans use the federally administered external review instead. Your final denial letter states which process applies and how to file.

Does Georgia's independent review cost anything?

No. Georgia law requires the managed care entity to pay the full cost of the independent review (O.C.G.A. § 33-20A-34).

Who has to prove their case?

The insurer. Georgia's implementing regulation places the burden of proof on the managed care entity in all questions before the independent review organization — an unusually consumer-friendly rule.

Is there a minimum claim size?

For the state track, yes — the proposed treatment must cost at least $500. The federal external review process has no such minimum.

What's happening with the federal external review portal?

As of July 2026, CMS reports the HHS-administered federal external review process is temporarily unavailable and says HHS will provide information about extending deadlines. If your plan uses the federal track, document everything, watch the CMS external appeals page, and ask your insurer whether it contracts with an accredited independent review organization directly.

Primary sources

Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.

Internal appeal first, external review second. We’ll map your path.

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