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.
- the New York State Department of Financial Services at 1-800-400-8882
- the New York State Department of Health at (518) 486-6074
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.
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.