NYSID Guide to HMOs

What are utilization review appeals?

Current performance area: Internal Appeals
Compare: Selected HMOs
Source: NYSID, 2006

Plans are listed in alphabetical order.

Click here for the pdf version of the table
HMO Filed Appeals Closed Appeals1 Reversed Appeals Appeals Reversal Rate
Aetna Health 673 658 286 43%
Atlantis2 -- -- -- --
CDPHP 420 418 166 40%
CIGNA 367 375 188 50%
Community Blue (HealthNow) 682 667 289 43%
Empire HealthChoice 198 198 61 31%
Excellus 970 954 326 34%
GHI-HMO Select 199 205 121 59%
Health Net of NY 2,232 2,256 778 34%
HIP 112 65 33 51%
IHA3 50 49 35 71%
MDNY 305 323 138 43%
MVP Health Plan 236 241 41 17%
Oxford 4,684 4,675 2,133 46%
Rochester Area HMO (Preferred Care) 139 151 47 31%
UnitedHealthcare of NY 13 13 7 54%
Total 11,280 11,248 4,649 Avg.=43%

Closed internal appeals can exceed filed UR appeals in 2006 because closed internal appeals also include UR appeals filed prior to 2006.
Atlantis Health Plan has the minimum premium required to report data, but did not report the data by the deadline, so the data are not reported in this Guide.
Includes appeals for the Art. 43 managed care contracts.

Understanding the Table

An internal appeal or utilization review (UR) appeal occurs when a consumer asks an HMO to reconsider its refusal to pay for a medical service the insurer considers experimental, investigational, or not medically necessary. HMOs are required to have medical professionals review appeals. Common internal appeals involve the medical necessity of hospital admissions, the length of hospital stays, and the use of certain medical procedures. For each HMO, the table will tell you:

  • Number of filed appeals - Internal appeals submitted to the HMO by consumers in 2005.

  • Number of closed appeals - Internal appeals that the HMO was able to reach a decision on by the close of 2005.

  • Number of reversed appeals - Internal appeals that the HMO decided in favor of the consumer. If an internal appeal decision is reversed on appeal, the HMO agrees to pay for the service or procedure.

  • Reversal rate - Percentage of appeals decided in favor of the consumer; i.e., the HMO agrees to pay for the service.

Keep in mind...

You should pay specific attention to a HMO that has a very high or very low reversal rate.

  • A low reversal rate may indicate that the HMO is making its initial decisions correctly, so fewer of these decisions require reversal. However, an unusually low reversal rate may indicate that the HMO is not giving appropriate reconsideration to its initial decisions.
  • A high reversal rate may indicate that an HMO's appeals process is responsive to consumers. However, an unusually high reversal rate may indicate that the HMO's process for making initial medical necessity decisions is flawed.

Please note the following:

  • There is no ideal reversal rate.
  • The number of internal appeals filed may be higher for HMOs that actively promote the appeals process and encourage members to appeal denied services.

The Utilization Review Appeals Category is only one of eight performance areas presented.


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Copyright © 2006 New York State Insurance Department