First-level, second-level, and external review: appeal levels explained
Most denied claims travel a defined path: an internal first-level appeal decided by the payer, a second internal level with a different reviewer, and then review outside the payer entirely. Each level has its own filing window, and skipping a level usually forfeits it.
What is a first-level appeal?
The first formal request that the payer reconsider its decision, decided by the payer's own staff. This is where many denials get resolved, because many denials trace to missing information the appeal supplies.
What is a second-level appeal?
A second internal review, typically by a reviewer who was not involved in the first decision — for clinical denials, often a clinical peer. The second level is the place to answer whatever reason the first-level decision gave for upholding the denial.
What is external review?
Review by an independent organization outside the payer, available after internal levels are exhausted on products that carry the right. Who provides it depends on the regulator: state-regulated products use the state's review program, while other products use an independent review organization under federal rules.
Do all claims get every level?
No — the levels available depend on the product and its regulator, and provider payment disputes sometimes follow a different track than member-benefit appeals. The denial letter is required to describe the review rights that apply, so read it before planning the escalation.