On May 24, 1999, a group of state and federal officials met in Washington, DC, to discuss state experiences with external appeal mechanisms. The meeting was sponsored by the National Academy for State Health Policy (NASHP) and made possible through financial support from The David and Lucile Packard Foundation. The meeting allowed exchange of information between state officials who have designed and operated external appeals systems and their federal counterparts, who are crafting potential federal approaches to external appeals. Officials from four states – Missouri, New Jersey, Texas and Vermont – were invited to attend the NASHP meeting. Based on survey findings, these states were selected as a good representation of the types and tenure of appeal systems.