New York State External Appeals
A member has a right to an external appeal of a final adverse determination. New York State's External Appeal Law provides the opportunity for the external review of adverse determinations for members and providers based on lack of medical necessity, experimental or investigational treatment, a clinical trial, or (in certain instances) out-of-network services. Further, a member, the member's designee, and, in conjunction with concurrent and retrospective adverse determinations, a member's health care provider has the right to request an external appeal.
This law also applies to rare diseases, which are defined as any life threatening or disabling condition that is, or was subject to review, by the National Institutes of Health's Rare Disease Council or affects less than 200,000 US residents per year and there is no standard health service or treatment more beneficial than the requested health service or treatment. To qualify as a rare disease, the condition must be certified by an outside physician specialized in an area appropriate to treat the disease in question, the patient should be likely to benefit from the proposed treatment and the benefits must outweigh the risks.
The provider may only file an external review on their own behalf for concurrent and retrospective adverse determinations.
The Circumstances When an External Appeal May Be Filed
1. When the member has had coverage of a health care service, which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, on the grounds that such health care service is not medically necessary; and
2. EmblemHealth has rendered a final adverse determination with respect to such health care service; or
3. both EmblemHealth and the member have jointly agreed to waive any internal appeal.
An External Appeal May Also Be Filed
1. When the member has had coverage of a health care service denied on the basis that such service is experimental or investigational; and
2. The denial has been upheld on appeal or both EmblemHealth and the member have jointly agreed to waive any internal appeal; and
3. The member's attending physician has certified that the member has a life-threatening or disabling condition or disease:
- For which standard health services or procedures have been ineffective or would be medically inappropriate; or
- For which there does not exist a more beneficial standard health service or procedure covered by the health care plan; or
- For which there exists a clinical trial or rare disease treatment; and
4. The member's attending physician, who must be a licensed, board-certified, or board-eligible physician qualified to practice in the area of practice appropriate to treat the member's life-threatening or disabling condition or disease, must have recommended either:
- A health service or procedure (including a pharmaceutical product within the meaning of PHL 4900(5)(b)(B)) that, based on two documents from the available medical and scientific evidence, is likely to be more beneficial to the member than any covered standard health service or procedure, or in the case of a rare disease, based on the physician's certification required by Section 4900 (7)(g) of the PHL and such other evidence as the member, the designee, or the attending doctor may present, that the requested health service or procedure is likely to benefit the member in the treatment of the enrollee's rare disease and that the benefit outweighs the risks of such health service or procedure; or
- A clinical trial for which the member is eligible. Any physician certification provided under this section shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation; and
5. The specific health service or procedure recommended by the attending physician would otherwise be covered under the policy except for the health care plan's determination that the health service or procedure is experimental or investigational.
External Appeal for Denial of Out-of-Network Service
The member has had coverage of the health service, which would otherwise be a covered benefit under the member's benefit plan, which is denied on appeal, in whole or in part, on the grounds that such health service is out-of-network and an alternate recommended health service is available in-network, and EmblemHealth has rendered a final adverse determination with respect to an out-of-network denial or both EmblemHealth and the member have jointly agreed to waive any internal appeal; and
The member's attending doctor, who shall be a licensed, board-certified, or eligible physician qualified to practice in the specialty area of practice appropriate to treat the member for the health service sought, certifies that the out-of-network health service is materially different from the alternate recommended in-network service, and recommends a health care service that, based on two documents from the available medical and scientific evidence, is likely to be more clinically beneficial than the alternate recommended in-network treatment and the adverse risk of the requested health service would likely not be substantially increased over the alternate recommended in-network health service.
EmblemHealth has only one level of internal appeal. It does not require the member to exhaust any second level of internal appeal to be eligible for an external appeal.
How to File an External Clinical Appeal
To file an external clinical appeal, the practitioner appealing on his/her own behalf must complete a New York State External Appeal Application, and send it to the New York State Department of Financial Services within 60 days (45 days before July 1, 2014) from the date of the final adverse determination of the first level appeal.
The member and member's designee (including the provider in the capacity of the member's designee) may submit the same form within four (4) months of the final adverse determination. If the member files on their own behalf, signed applications authorizing the release of medical records must also be sent to the New York State Department of Financial Services along with the application. (Note: Application fees are waived for Child Health Plus members.)
An external appeal must be submitted within the applicable time frame upon receipt of the final adverse determination of the first level appeal, regardless of whether or not a second level appeal is requested. If a member chooses to request a second level internal appeal, the time may expire for the member to request an external appeal. Second level internal appeals are for GHI PPO FEHB plan participating providers only.
The New York State Department of Financial Services screens applications and assigns eligible appeals to state-certified external appeals agents. The Department of Financial Services then notifies both the filer and EmblemHealth whether the request is eligible for appeal, provides explanation thereof, and sends a copy of the signed release form.
EmblemHealth will provide medical and treatment records and an itemization of the clinical standards used to determine medical necessity within three business days of receiving the agent's information and completed release forms. For an expedited appeal, this information will be provided within 24 hours of receipt.
For urgent medical circumstances, an expedited review may be requested which will render a decision within three days.
For standard cases, a determination will be made within 30 days from receipt of the member's request, in accordance with the commissioner's instructions. The external appeal agent shall have the opportunity to request additional information from the member, practitioner and EmblemHealth within the 30-day period, in which case the agent shall have up to five additional business days to make a determination.
The decision of the external appeal agent is final and binding on both the member and EmblemHealth.
To obtain an application or to inquire about external appeals, please contact the New York State Department of Financial Services at 800-400-8882 or email firstname.lastname@example.org.
Note: Practitioners appealing concurrent review determinations cannot pursue reimbursement from members other than copayments from a member for services deemed not medically necessary by the external appeal agent.