The NYS External
A Message from...
On July 1, 1999, the External Review Law of New York went into effect. This marked the beginning of a new era in consumer protection for persons belonging to managed care health programs.
The State Legislature passed this law to allow consumers to request an independent review of their health planís decision if a health claim has been denied.
This flyer explains the law, including where you can get more information or how to obtain an external appeal application.
As always, feel free to contact my office if you have any questions on this or any issue.
|What you should know...|
Can Consumers Appeal Their HMOís Decisions?
The External Appeals Law provides an independent appeal process for reasons of medical necessity for New Yorkers who have been denied health insurance benefits.
The law also allows consumers to appeal decisions when a treatment or service is denied because it is considered to be experimental or investigational in nature.
Consumers can file an application with the State Department of Insurance requesting an external appeal agent review the case.
This law will help ensure consumers have access to an independent expert review of what is appropriate and what is best for them medically.
How Does The External Appeal Process Work?
To be eligible for an independent appeal, a consumer must have first used the health planís internal appeal process and received a denial on or after July 1, 1999, or both the plan and the consumer must agree to waive their rights to the internal review and move directly to an independent external review.
The external appeal process does not replace the planís internal process. If, after going through the first level appeal of the internal process, the consumer (or a provider in some cases) still disagrees with the decision, they can apply to the New York State Department of Insurance to request to have the appeal reviewed by an external agent that is independent from your health plan.
How Can A Consumer Get An External Appeal Application?
When a health plan issues a final adverse determination at the first level of appeal, the plan must provide the consumer written notification of the decision, including the reason for the denial; a description of the external appeal process; and the application form and instructions for filing the application.
Persons can also obtain an external appeal application from the State Department of Insurance or the State Department of Health by calling the numbers listed on the back of this flyer.
Who Decides An External Appeal?
The Department of Insurance reviews all external appeal applications. If the department determines the applicant is eligible, an external appeal agent is appointed. External appeal agents must not have any affiliation with the health care plan to prevent any conflict of interest. The selected external appeal agent will review the request to determine if the denied service is medically necessary and should be covered by the plan.
When Must An Appeal Be Filed?
Under the law, persons have 45 days from the date they received a final determination from the planís internal appeal process to file for external review. External appeal agents have 30 days to make a decision. For emergency cases, the Insurance Department can turn a complete application around within 24 hours and the reviewer renders a decision within three days.
Consumers lose their right to appeal if they donít file an application with the Insurance Department for an external appeal within 45 days after the final adverse decision from the first level internal plan appeal.
What Does An External Appeal Cost?
Plans may charge a fee (no more than $50) that must be included with the application for an external appeal. This money will be refunded if the appeal is decided in their favor. If you can demonstrate financial hardship, the fee may be waived. For those covered under Medicaid or Child Health Plus, there is no fee.
Are Health Plans Bound By These Decisions?
Health plans must abide by the decision of the impartial panel or face stiff penalties and sanctions by the state.
What If My Employer Is Self-Insured?
If you are a member of a self-insured plan, you are NOT eligible for external review. Federal law prohibits states from regulating self-insured plans. If you are unsure if your coverage is self-insured, check with your employer.
|Important Phone Numbers|
Department of Insurance