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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).

Deadlines

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.

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 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.  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 an External Appeal

Complete the New York State External Appeal Application using the fillable PDF form below, and send it by email to earesponse@dfs.ny.gov, or fax (800) 332-2729 or by certified or registered mail to the Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210 (Note: This is a new address effective 2/1/2018). 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 Needed Depending on Appeal Type

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.

  1. 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, therefore 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 their 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.

  2. Physician Attestation Form – One of the physician attestation form below may be required depending on your appeal type.  An actual signature is required, therefore please download a printable copy to be signed.  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 that 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. 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 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 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 externalappealquestions@dfs.ny.gov. If you are faxing an expedited appeal call (888) 990-3991.

External Appeal Forms in Other Languages

 

Updated 08/22/2018

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