External Appeals

You may be eligible for an External Appeal

Most managed care enrollees have the right to request an independent agency to review their case if a managed care plan denies coverage of a health care service because it has determined that the service is not medically necessary or is experimental or investigational.

You must first appeal the denial with your plan, or you and your plan must agree to waive the internal appeal process. Applications for an external appeal must be filed within 45 days of the plan's final adverse determination from the first level of appeal or from receipt of the plan's letter waiving the internal appeal process. Providers may also request an external appeal to obtain payment from a plan when there has been a retrospective adverse determination.

More information and applications are available from the New York State Department of Financial Services or by calling 1-800-400-8882.