Independent Appeals from Health Insurance Denials-NY.

Patients Can Appeal Health Insurance Denials to Independent Reviewers Under a Law in New York.

Table of Contents

Frequently Asked Questions.

External Appeal Application For Consumers and Instructions.

External Appeal Application For Health Care Providers.

Statutes and Regulations.

Information About Certification of Organizations Who Conduct External Review.

Overview.

Effective July 1, 1999, a patient in New York can get an independent review of certain denials of insurance coverage by filing an appeal to an Independent External Review Organization chosen by the New York State Insurance Department. An external appeal is available when a patient's health plan denies coverage of a service on the grounds that the service is not "medically necessary" (a so-called "utilization review" denial).

Patients with a life-threatening or disabling condition or disease also will have the right to appeal a denial of coverage of a treatment when the denial is based on a health plan decision that the treatment is experimental or investigational. In order to be entitled to appeal a denial on this basis, a patient’s physician will have to certify that (1) standard health services or procedures have been ineffective or would be medically inappropriate; or (2) there does not exist a more beneficial standard health service or procedure covered by the patient’s health plan; or (3) the patient is eligible for a clinical trial. In addition, the patient's physician must certify that the recommended treatment is likely to be more beneficial to the patient than any standard treatment which might be covered by the patient's insurance or that the treatment is part of a clinical trial.

There are deadlines for requesting an external appeal so it is important to act promptly as soon as you receive a denial from your health plan. Information about these deadlines are in the External Appeal Application and Instructions for Consumers, and the Frequently Asked Questions located on the website of the New York State Insurance Department and in the External Review Statutes and Regulations.

If you have any questions about external appeals, you can contact the New York State Insurance Department at 1-800-400-8882.

Information On How To File An Appeal.

Frequently Asked Questions.
The New York State Insurance Department has published on its website a series of questions and answers about the appeal process. You can reach this information by clicking HERE for the Frequently Asked Questions section of the Department's website.

External Appeal Application and Instructions for Consumers.
You can obtain a copy of the External Appeal Application and instructions from a number of places.

The Instructions are available by clicking HERE.
The Application is available in Adobe Acrobat format on the Insurance Department website. Go to the Frequently Asked Questions page by Clicking HERE. Scroll down the page until you come to the link entitled: "New York State External Appeal Application (For Health Care Consumers)" . Click on this link and if you have the Adobe Acrobat reader, you will see the Application and Instructions. If you do not have adobe acrobat installed on your computer, there is a link on the Insurance Department website to Adobe's website where you can obtain this software for free.

You can also obtain a copy of the Application and Instructions from the Insurance Department by calling 1-800-400-8882.

You can request an Application from your health plan at any time. In addition, your health plan must provide you with the Application whenever the health plan makes a final decision denying health insurance coverage - called a "final adverse determination" - on the grounds that the services you are requesting are not "medically necessary".

External Appeal Application for Health Care Providers.

This Application is available in Adobe Acrobat format on the Insurance Department's Frequently Asked Questions webpage by Clicking HERE .

Statutes and Regulations.

The main provisions of the New York External Review law are contained in the following statutes. The regulations are listed after the statutes.Click on the links below to view the statutes and regulations..

Public Health Law Article 49 Title II

Insurance Law Article Article 49 Title II

Chapter 586 of the Laws of 1998, the External Review Law in bill form as it passed the New York State legislature and was signed by the Governor. Scroll down to the bottom of the Frequently Asked Questions page on the Insurance Department's website and you will find a link to chapter 586.

Insurance Department External Review Regulations, 11 NYCRR 410 adopted on February 14, 2001. You will need the adobe acrobat reader to view this file.

Information About Organizations That Conduct External Review.

Information about organizations certified to conduct external reviews, can be found on the New York State Department of Insurance website by Clicking HERE.

This article originally appeared in our January 1999 newsletter. It has since been updated.

Insurance Coverage For Experimental and Investigational Treatments Under Different State Laws.