Your External Appeals Rights

If you disagree with certain coverage decisions, you can request an appeal by someone other than EmblemHealth.

You have the right to an external appeal when health care services are denied as not medically necessary, experimental/investigational, a clinical trial, and a rare disease treatment or, in certain cases, as out-of-network.

Providers also have their own rights to an external appeal when these health care services are denied concurrently or retrospectively. External appeal requests must be submitted to the New York State Department of Financial Services (DFS). DFS will assign independent medical experts to review the appeal.

These medical experts may overturn your plan’s decision in whole or in part. Or, they may uphold your plan’s denial of coverage. Their decision is binding on both you and your plan.

To appeal to DFS, you first request your plan’s internal appeal. You have 180 days to request an internal appeal from your plan after receiving your Adverse Determination (denial). If we uphold the original denial, you will receive a letter known as a Final Adverse Determination.

You have four months after you receive our final adverse decision on your appeal to ask for an external appeal. If you and your plan agree to skip our appeal process, you must ask for the external appeal within four months after the agreement with your plan is made.

Keep in mind that to file an external appeal, the health care services had to have been denied as not medically necessary, experimental/investigational, a clinical trial, a rare disease treatment or, in certain cases, as out-of-network. When we issue a final adverse determination denial, you will receive instructions on how to file an external appeal along with an external appeal application.

If you have questions or if you need help with an external appeal application, call DFS at 800-400-8882 or visit their website, dfs.ny.gov.

Note: The DFS external appeal process does not apply to federal employees or Administrative Services Only (ASO) members.