New York State External Appeal
If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network, you have the right to appeal to the Department of Financial Services (DFS). 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).
Prior External Appeal Decisions
Search and review prior external appeal decisions using our External Appeals Database. Data can be searched by year, diagnosis, treatment, or key words like cancer, apnea, etc.
Deadlines
You must send an appeal application to DFS within 4 months from the date of the final adverse determination from your internal appeal with the health plan, or 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.
Fees
Health plans may charge a $25.00 fee per appeal (but not more than $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 poses a hardship. Health plans may charge providers a $50.00 fee per appeal. The fee will be returned if the external appeal agent overturns the denial.
The No Surprises Act (NSA)
You may file an external appeal if your health plan issued a final adverse determination for any of the following reasons:
- The health plan determined that out-of-network emergency services received were not emergencies
- The health plan determined that the out-of-network services received do not qualify as a surprise bill
- Incorrect cost-sharing was applied to your bill for either emergency services or a surprise bill
- There is a question about whether the claim for out-of-network care you received was coded correctly by the provider and accurately reflects the treatment you received, and the associated NSA protections related to cost sharing and surprise billing.
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, or the patient is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function, or is undergoing a current course of treatment using a non-formulary drug.
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 (or 24 hours for a non-formulary drug), even if all of the patient's medical information has not yet been submitted.
Submit (or Add Information to) an External Appeal
Complete the New York State External Appeal Application online. Our External Appeal Application Instructions may help you with your submission.
To get started visit the DFS Portal:
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.
Forms
Use the links below to download the necessary form(s) for your appeal. If you send these after the appeal has been submitted, please include the DFS Case number on the form(s). Eligibility screening of the external appeal cannot be completed without all required documents.
Patient Consent to the Release of Records
| Link to Form | Description |
|---|---|
| Patient Consent Form | This form will be used to obtain privacy protected medical records. An actual signature is required. This form must be signed by the patient or their authorized representative. If the patient is a minor, the document must be signed by the parent or legal guardian. If the patient is deceased, the document must be signed by the patients’ healthcare proxy or executor. If signed by a guardian, healthcare proxy or executor, a copy of the legal supporting document should be included. |
Physician Attestation Form
One of the physician attestation forms below may be required depending on your appeal type. An actual signature is required. To appeal an experimental/investigational, clinical trial, out-of-network service or out-of-network referral denial, the physician must be licensed and board-certified or board-eligible and qualified to practice in the area of practice appropriate to treat the patient. For a rare disease appeal, a physician must meet the above requirements, but may be different than the patient’s treating physician.
| Link to Form | Description |
|---|---|
| Comprehensive Physician Attestation Form | For all appeal types |
| Medical Necessity – Expedited | This form is only needed for expedited Medical Necessity appeals. No Physician Attestation is required for standard Medical Necessity appeals. |
| Experimental/Investigational | Standard health services or procedures have been ineffective or would be medically inappropriate, or there does not exist a more beneficial standard health service or procedure covered by the health plan. |
| Clinical Trial | There exists a clinical trial which is open, for which the patient is eligible and has been or will likely be accepted. |
| Rare Disease | The attesting physician may be different than the patient’s treating physician. The patient has a rare condition or disease for which there is no standard treatment that is likely to be more clinically beneficial to the patient than the requested service. The requested service is likely to benefit the patient in the treatment of the patient’s rare disease, and such benefit outweighs the risk of the service. |
| Out-of-Network Referral | The health plan does not have an in-network provider with the appropriate training and experience to meet the health care needs of the patient. |
| Out-of-Network Service | The health plan offers an alternate in-network service that is not materially different from the out-of-network service. |
| Formulary Exception – Expedited | The patient’s physician or prescriber must complete this attestation for any expedited formulary exception appeal. No Physician Attestation is required for standard Formulary Exception appeals |
The External Appeal Agent
You will be notified when your appeal is assigned to an external appeal agent, who will request supporting documents. 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 24 hours for a non-formulary drug), or 30 days for standard appeals (or 72 hours for a non-formulary drug). 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 otda.ny.gov/hearings for fair hearing information.
Questions?
For questions or help with an application call (800) 400-8882 or email [email protected]. If you are faxing an expedited appeal call (888) 990-3991.
External Appeal Forms in Hard Copy
Online submission is preferred, but you may instead complete the fillable PDF form below, and send it by email to [email protected], by fax to (800) 332-2729 or by certified/registered mail to the Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210.
External Appeal Application Form in Other Languages
External Appeal Application Instructions in Other Languages
Language Access
Our goal is to provide you with satisfactory translation and interpretation services. If you feel you have been denied any available translated documents or interpretation service and would like to submit a complaint, visit our Language Access Information page.