By state / Puerto Rico

Puerto Rico

Regulator

Puerto Rico Office of the Insurance Commissioner

External review

State-run. Request it through the regulator after the plan's final internal denial; the federal floor is 4 months (45 CFR 147.136).

Published reversal rate

Not published by the regulator · source

Notes

KFF 2024 classifies Puerto Rico as operating an NAIC-parallel state-run external-review process; OCS does not publish public overturn statistics.

Before external review

File the plan's internal appeal first (at least 180 days for ACA-compliant plans; the letter states the date). Ask for the claim file and the criteria the plan applied; both are free on request. Self-funded employer plans use the federal external review and the U.S. Department of Labor, not the state.

More on Puerto Rico: state appeal rights · External Review Index entry · insurer denial rates (HealthCare.gov states).

Verified 2026-09-15. The regulator's site and your denial notice control.