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External Appeals

You have the right to an external appeal when health care services are denied by an HMO or insurer (health plan) as not medically necessary, experimental/investigational, a clinical trial, a rare disease treatment, or, in certain cases, as out-of-network.

Health care providers may request an external appeal on their own behalf to obtain payment when a health plan makes a concurrent or retrospective adverse determination denying health care services as not medically necessary, experimental/ investigational, a clinical trial or a rare disease treatment.

To file an external appeal, read the External Appeal Application Instructions and complete the New York State External Appeal Application and send it to DFS within 4 months (or 60 days for provider appeals) of the health plan’s first-level appeal determination. You can submit the appeal via fax to (800) 332-2729 or by certified or registered mail.

If eligible, the Department will have the appeal reviewed by an independent medical expert known as an External Appeals Agent.

If you have questions about your external appeal rights after reading the external appeal instructions, check the Consumer & Provider External Appeal FAQs.

If you still need help, call the DFS at (800) 400-8882 or email Externalappealquestions@dfs.ny.gov. If you need help with an expedited appeal on a weekend or holiday, call (888) 990-3991.


External Appeal Application Instructions

Deadlines

An External Appeal Application must be submitted to DFS no later than 4 months from the date of the final adverse determination from the first level of appeal with the health plan OR the waiver of the internal appeal process. If your health plan offers a second-level Internal appeal you do not have to file one, but if you do, you must still submit an external appeal to DFS within 4 months of the first appeal decision.

Experimental/Investigational Denials

The patient’s physician (for rare diseases cannot be the treating physician) must complete and send pages 4-6 to DFS along with medical literature supporting the services.

Out-Of-Network Denials

The patient must have an HMO or managed care insurance contract and a pre-authorization request must be denied because the service is not available in-network and the health plan recommends an alternate in-network service that it believes is not materially different from the out-of-network service. The patient’s physician must complete and send pages 4-6 of the application to DFS.

Fees

Health plans may charge a $25.00 fee to patients or their designees, not to exceed $75.00 in a single plan year. The fee is returned if the external appeal agent overturns the denial. The fee is waived for patients who appeal and are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship.

Providers Appeals

Providers have their own right to an external appeal when health care services are denied concurrently or retrospectively.Providers appealing on their own behalf must submit an external appeal within 60 days of the final adverse determination. If you do not send your application to DFS within the required timeframe (allow an additional 8 days for mailing), you will not be eligible for an external appeal.

Health plans may charge providers a $50.00 fee per appeal. The fee is returned if the external appeal agent overturns the denial.

Expedited (Fast-Tracked) External Appeal

To be expedited, a denial must be related to an admission, availability of care, continued stay, or health care service for which the patient received emergency services and remains hospitalized; or the patient’s physician must complete pages 4-6 of the application and attest that the patient has not received the treatment and a 30 day timeframe would seriously jeopardize the patient’s life, health, or ability to regain maximum function; or a delay would pose an imminent or serious threat to the patient’s health.

A patient may request an expedited internal and external appeal at the same time. Once an external appeal is expedited, a decision is made in 72 hours, even if all of the patient’s medical information has not yet been submitted. If you are faxing an expedited appeal call (888) 990-3991.

The External Appeals Agent

You will be notified when an external appeals agent is assigned to your case. Send all pertinent information to the agent immediately. The Agent will make a decision within 72 hours of receipt for expedited appeals or 30 days for standard appeals. Once the agent makes a decision, additional information will not be considered, and the agent’s decision is binding on the patient and the health plan.

Medicare & Medicaid Eligibility

Patients covered under Medicare are not eligible for external appeal and should instead call (800) MEDICARE or visit www.medicare.gov. Patients covered under regular Medicaid are not eligible for external appeal, however, patients covered under a Medicaid Managed Care Plan are eligible. All Medicaid patients may request a fair hearing, and the fair hearing decision will be the one that applies. Call (800) 342-3334 or visit otda.ny.gov/hearings for more information about fair hearings.

Updated 10/21/2014

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