External Review Laws

Independent External Appeal

As of July 1, 1999, health care consumers have even greater protection under New York State law. The state’s external appeal law gives consumers the right to have an external appeal agent (an independent panel of medical experts) review certain health plan decisions about health care services to determine that they are medically necessary. New York’s external appeal law allows health care consumers to seek this impartial review in any case where a health plan denies coverage for care it determines is not medically necessary or when a health plan denies a treatment or service because it is experimental or investigational in nature. In such cases, the consumer can file an application with the state Department of Financial Services requesting that an external appeal agent review the case.

Experimental Treatments

By their very definition, experimental treatments have not yet been established as standard care. HMOs and other health plans often participate in clinical trials designed to test the effectiveness of experimental and investigational procedures. However, most health plans have strict criteria relating to coverage of these procedures.

It is important to remember that “newest” doesn’t always mean most appropriate. To help make those determinations, a patient (or someone acting on behalf of the patient) has the right to seek an external appeal of a plan’s denial of coverage on the basis that the plan considers the treatment experimental or investigational.

The external appeal law seeks to build consumer confidence about managed care by ensuring consumers have access to an independent review process to determine if a particular health care service is medically necessary and appropriate.

Frequently Asked Questions

New Yorks Managed Care Act—FAQs About External Appeal

As of July 1, 1999, New York State law provides consumers the right to have an external appeal agent (an independent panel of medical experts) review certain health plan decisions about health care services to determine that they are medically necessary. New York’s external appeal law allows health care consumers to seek this impartial review in any case where a health plan denies coverage for care it determines is not medically necessary or when a health plan denies a treatment or service because it is experimental or investigational in nature. In such cases, the consumer can file an application with the state Department of Insurance requesting that an external appeal agent review the case.

How does the external appeal process work?

All health plans have processes in place for reviewing whether a coverage decision is appropriate. The external appeal law does not replace the plan’s internal process. If, after going through the internal process, first-level appeal, you (or a provider, in certain cases) still disagree with the decision, you can apply to the New York State Department of Financial Services to ask to have the appeal reviewed by an external agent that is independent from your health plan.

How do I get an external appeal application?

When a 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. You may also obtain an external appeal application from:

Who decides if I get an external appeal and who does it?

The Department of Financial Services will review all external appeal applications. If the case is eligible, the department will notify you and send the case to an external appeal agent that has been randomly selected by the state. The selected external appeal agent approved by the state will review your request to determine if the denied service is medically necessary and should be covered by the plan. Medical experts (called “clinical peer reviewers”) conduct all external appeals. Safeguards against conflicts of interest help ensure the process is fair to all parties.

Is there a time limit for filing an appeal?

The application for an external appeal must be sent to the Department of Financial Services within 45 days of your receipt of the notice of a final adverse determination as a result of the plan’s first-level UR appeal process, or within 45 days of when you and the plan jointly agree to waive the internal appeal process. Additional internal plan appeals, which are optional, may be available to you. However, regardless of whether you participate in additional internal plan appeals, an application for external appeal must be filed with Department of Financial Services within 45 days from your receipt of the notice of final adverse determination from a first-level internal plan appeal to be eligible to be reviewed by an external appeal agent.

You will lose your right to an external appeal if you do not file an application for an external appeal within 45 days from your receipt of the final adverse determination from the first level internal plan appeal.

How long will it take to get a decision?

There are two types of appeals—standard and expedited. An external appeal agent must decide a standard appeal within 30 days of receiving your application from the state. Five (5) additional business days may be added if the agent needs additional information. If the agent determines that the information submitted to it is materially different from that considered by the plan, the plan will have three (3) additional business days to reconsider or affirm its decision. You and the plan will be notified within two (2) business days of the agent’s decision.

You may request an expedited appeal if your doctor can attest that delaying the recommended treatment would pose an imminent or serious threat to your health. In these cases, the external appeal agent will make a decision within three (3) days. Every reasonable effort will be made to notify you and the plan of the decision by telephone or fax immediately. This will be followed immediately by a written notice. The decision of the external appeal agent is final and binding on both you and the plan.

Does it cost anything to get an external appeal?

Plans may charge a small fee that must be included with the application for an external appeal. This money will be refunded if the appeal is decided in your favor. If you can demonstrate financial hardship, the fee may be waived. For consumers covered under Medicaid or the Child Health Plus program, there is no fee.