Whom to contact:

New York State Insurance Department

Who can appeal:

You, or your authorized representative, including your provider

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational.

When you can appeal:

You must request an external appeal within 45 days from receipt of the final adverse determination from the first level of internal appeal with your health plan, or within 45 days of receipt of a letter from your health plan agreeing to waive the internal appeal process.

What to send:

Completed application (a physician’s statement is required for Experimental/Investigational appeals) and a copy of the adverse determination letter or a letter from the health plan waiving the appeal.

What you must pay:

Up to $50 (the fee is waived under certain conditions). The fee is returned to the patient if the health plan denial is ultimately overturned.

What will happen:

The Insurance Department will:

1. Review the appeal request within 5 business days.
2. Assign the request to an external review agent if the request is eligible and complete.

The external review agent will:

1. Have a medical expert (or experts) review the appeal.
2. Determine the outcome.

When you will get a decision:

30 days (plus 5 business days if additional information is requested)

In urgent situations:

An expedited appeal will be reviewed by the Insurance Department within 24 hours and the outcome determined by the external review agent within 3 days.