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Your Right to Appeal an Insurer's Decision

If your insurer denies health care services that it considers experimental, investigational or not medically necessary, you can request an outside medical professional to review your case and issue a determination. This is called an independent external review. Reviews are conducted by external review organizations certified by the State of New York.

Here are the steps to appeal an Insurer's decision:

1. Follow your insurer's internal appeal process for denied services. Call the Member Services Department phone number on your insurance card for information on the appeal process.
2. If you are not satisfied with the decision you received from your insurer's internal appeal process, you can request an external review by submitting a completed application to the New York State Insurance Department within 45 days of receiving your insurer's decision. To request an independent external review application, contact the New York Insurance Department at 800-400-8882, or visit the Web site at www.ins.state.ny.us/extapp/extappqa.htm. With your application, you must submit a written notice from your insurer stating that:
   • a denial of health care services was upheld by the insurer's first-level internal appeal process, or
   • you and your insurer agreed to waive the internal appeal process.
   Your cost for an external review could be up to $50. However, the fee is refunded if the decision is in your favor.
3. After you submit a request for an external review, the Insurance Department will notify you and your health insurer whether your case qualifies. Your health insurer must then send your medical and treatment records to the external review organization. You and your doctor can submit additional information as soon as you are notified that an external appeal organization has been assigned to review your case.
4. There are two types of reviews: standard and expedited.
   • For a standard review, the external review organization must make a decision within 30 days of receiving your request for an external review from the State.
   • An expedited review can be requested if your doctor determines that a delay in providing the treatment or service poses an immediate or serious threat to your health. Your doctor must send written testimony about your need for immediate care to the Insurance Department. The external review organization must make a decision within 3 days of receiving your request for an expedited external review from the State.
5. The external review organization will notify you of its decision as follows:
   1. If your review was standard, you and your health insurer will be notified in writing within two business days of the external review organization's decision.
   2. If your review was expedited, reasonable efforts will be made to contact you and your health insurer by phone or fax immediately following the decision. Written notification will follow.

The decision of the external review organization is final and binding for you and your health plan, meaning that the decision cannot be changed or altered by either party.

Eligibility

You are not eligible to appeal your insurer's coverage decision through the external review process if: The service or treatment you are seeking is not a covered benefit under your plan. Medicare is your only source of health services. Your health plan is a self-insured plan (sometimes known as an ERISA plan), which is not subject to state regulation. The review is for Workers' Compensation claims or for claims under no-fault auto coverage. Your health coverage was issued outside of New York.

Independent External Review Data

You can find data regarding the total number of external reviews, number of reversed reviews, number of reversed in part reviews and upheld reviews for health insurers.