New York State External Appeal
You have the right to appeal to the Department of Financial Services (DFS) when your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network. This appeal is known as an external appeal. Health care providers also have the right to an external appeal when health care services are denied (concurrently or retrospectively).
Consumers must send an external appeal application to DFS within 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. If DFS does not receive your application within 4 months, you will not be eligible for an external appeal. Providers appealing on their own behalf must submit an external appeal within 60 days of the final adverse determination.
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 waived for patients who are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. Health plans may charge providers a $50.00 fee per appeal. This fee will be returned if the external appeal agent overturns the denial.
Expedited (Fast-Tracked) External Appeals
For an external appeal to be expedited, the denial must concern 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 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 will 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. A decision on an expedited external appeal will be made within 72 hours, even if all of the patient's medical information has not yet been submitted.
Submit an External Appeal
Complete the New York State External Appeal Application and send it by fax to (800) 332-2729 or by certified or registered mail to the Department of Financial Services, PO Box 7209, Albany NY, 12224. If eligible, DFS will have the appeal reviewed by an independent external appeal agent that will either overturn (in whole or part) or uphold the denial.
Experimental/Investigational Denial (including Clinical Trial and Rare Disease)
The patient's physician (for rare diseases this cannot be the treating physician) must complete pages 4 - 7 of the application and send to DFS.
There are two types of out-of-network denials that are eligible for external appeal. The first is an out-of-network service denial. For these, the patient must have a pre-authorization request 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 second is an out-of-network referral denial. For these, the patient's out-of-network referral request must be denied because the health plan has an in-network provider with appropriate training and experience to meet the particular health care needs of the patient. For an out-of-network service denial or referral denial, the patient's physician must complete pages 4 - 7 of the application and send to DFS.
The External Appeal Agent
You will be notified when your appeal is assigned to an external appeal agent, who will request supporting documents. You should respond immediately to that request. Once the agent makes a decision, additional information will not be considered. The agent will make a decision within 72 hours for expedited appeals or 30 days for standard appeals. The external appeal agent's decision is binding on the patient and the patient's health plan.
Patients covered under Medicare are not eligible for an external appeal and should call (800) MEDICARE or visit www.medicare.gov. Patients covered under regular Medicaid are not eligible for an external appeal; however, patients covered under a Medicaid Managed Care Plan are eligible. All Medicaid patients may also request a fair hearing, and the fair hearing decision will be the one that applies. Call (800) 342-3334 or visit www.otda.state.ny.us/oah for fair hearing information.
For questions or help with an application visit www.dfs.ny.gov/ExternalAppeal, call (800) 400-8882 or email firstname.lastname@example.org. If you are faxing an expedited appeal call (888) 990-3991.