File an External Appeal | Department of Financial Services

new york state external appeal

If your insurer or hmo denies health care services as not medically necessary, experimental/investigational, or out-of-network, you have the right to appeal to the department of financial services (dfs) . this appeal is known as an external appeal. health care providers also have the right to an external appeal when health care services are denied (concurrently or retrospectively).

external appeal decisions

Search and review prior external appeal decisions using our external appeals database. data can be searched by year, diagnosis, treatment, or keywords such as cancer, apnea, etc.

Reading: How to file an insurance appeal

deadlines

Consumers must submit an external appeal request to dfs within 4 months from the date of the final adverse determination of the first level of appeal with the health plan or the waiver of the internal appeal process. If your health plan offers a second level internal appeal, you do not have to file one, but if you do, you must still file an external appeal with dfs within 4 months of the first appeal decision. If dfs does not receive your request within 4 months, you will not be eligible for an external appeal. providers appealing on their own behalf must file an external appeal within 60 days of the final adverse determination.

fees

Health plans may charge patients or their designees a fee of $25.00, not to exceed $75.00 in a single plan year. the fee is waived for patients who are covered by medicaid, child health plus, family health plus, or if the fee represents a hardship. health plans may charge providers a fee of $50.00 per appeal. this fee will be returned if the external appeal agent overturns the denial.

no surprise act (nsa):

You may file an external appeal if your health plan issued a final adverse determination for any of the following reasons:

• The health plan determines that emergency services received out-of-network were not emergencies; or
• The health plan determines that services received out-of-network do not qualify as a surprise bill; or
• an incorrect cost share was applied to your bill for emergency services or a surprise bill; or
• there is a question as to whether the provider correctly coded the claim for out-of-network care you received and accurately reflects the treatment received and associated nsa protections related to cost-sharing and surprise billing.

expedited external appeals (fast track)

For an external appeal to be expedited, the denial must relate to an admission, availability of care, continued stay, or health care service for which the patient received emergency services and remains hospitalized; o The patient’s physician must certify that the patient has not received the treatment and that within 30 days would seriously jeopardize the patient’s life, health, or ability to regain maximum function, or a delay would pose an imminent threat or serious for the patient’s health. or the patient has a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function, or is undergoing current treatment with a drug that is not on the formulary. a patient can request an expedited internal and external appeal at the same time. A decision on an expedited external appeal will be made within 72 hours (or 24 hours for a non-formulary drug), even if all of the patient’s medical information has not yet been submitted.

submit or add information to an external appeal

Complete the new york state external appeal application online.

To get started, visit the dfs secure portal:

portal dfs

if eligible, dfs will have the appeal reviewed by an independent external appeal agent who will reverse (in whole or in part) or uphold the denial.

forms needed depending on the type of appeal

Use the links below to download the forms needed for your appeal. If you are submitting them after the appeal has been filed, please include the dfs case number on the forms. the external appeal eligibility review cannot be completed without all required documents.

1. patient consent for release of records

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patient consent form

This form will be used to obtain privacy-protected medical records. an actual signature is required. this form must be signed by the patient or their authorized representative. if the patient is a minor, the document must be signed by the parent or legal guardian. if the patient is deceased, the document must be signed by the patient’s health care agent or executor. if signed by a guardian, health care proxy, or executor, a copy of the supporting legal document must be included.

2. Medical Certification Form: One of the medical certification forms below may be required depending on the type of appeal. an actual signature is required, so download a printable copy to sign. to appeal a clinical/experimental, investigational trial, out-of-network service, or out-of-network referral, the physician must be licensed and board certified or board eligible and qualified to practice in the area good practice to treat the patient. for a rare disease appeal, a doctor must meet the above requirements, but may be different from the patient’s treating doctor.

complete medical certification form

for all appeal types

medical necessity – expedited

This form is only needed for expedited medical necessity appeals. a medical certificate is not required for standard medical necessity appeals.

experimental/investigative

Standard health services or procedures have been ineffective or would be medically inappropriate, or there is no more beneficial standard health service or procedure covered by the health plan.

clinical trial

there is a clinical trial that is open, for which the patient is eligible and has been or probably will be accepted.

rare disease

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The certifying physician may be different from the patient’s treating physician. the patient has a rare disease or condition for which there is no standard treatment that is likely to be more clinically beneficial to the patient than the requested service. the requested service is likely to benefit the patient in treating the patient’s rare disease, and such benefit outweighs the risk of the service.

off-net referral

The health plan does not have an in-network provider with the appropriate training and experience to meet the patient’s health care needs.

out-of-network service

The health plan offers an alternative in-network service that is not materially different from the out-of-network service.

form exception: throttled

The patient’s physician or prescriber must complete this certificate for any expedited formulary exception appeal. a medical certificate is not required for standard formulary exception appeals

the external appeal agent

You will be notified when your appeal is assigned to an external appeal agent, who will request supporting documents. respond immediately to that request. once the agent makes a decision, no additional information will be considered. the agent will make a decision within 72 hours for expedited appeals (or 24 hours for a non-formulary drug), or 30 days for standard appeals (or 72 hours for a non-formulary drug). the external appeal agent’s decision is binding on the patient and the patient’s health plan.

patients covered by medicare are not eligible for an external appeal and should call (800) medicare or visit www.medicare.gov. patients covered by regular medicaid are not eligible for an external appeal; however, patients covered by a medicaid managed care plan are eligible. all medicaid patients can also request a fair hearing, and the fair hearing decision will be upheld. Call (800) 342-3334 or visit https://otda.ny.gov/hearings/ for information on fair hearings.

questions?

If you have questions or need help with an application, please call (800) 400-8882 or email [email protected]. If you are faxing an expedited appeal, please call (888) 990-3991.

hard copy external appeal form

Online submissions are preferred, but if you wish, you may complete the fillable pdf form below and submit via email to [email protected], fax to (800) 332-2729, or mail certified/registered to the department of financial services, 99 washington avenue, box 177, albany, ny 12210.

• new york state external appeal application (fillable pdf)
• instructions for the external appeal request (pdf)

external appeal forms in other languages

• Spanish: New York State External Appeal Application (pdf). Call us at (800) 342-3736 if you need free help in your language.
• Bengali: নিউ ইয়র্ক স্টেটের বহিঃস্থ আপীলের আবেদন
• Chinese: 紐約州外部申訴申請表 (pdf).請給我們打電話號碼 (800) 342-3736, 要求免費的語言協助服務。
• Creole: aplikasyon apèl ekstèn eta new york (pdf). tanpri rele nou nan (800) 342-3736 pou jwenn sèvis èd toll free nan lang.

Italian

• : richiesta di ricorso esterno dello stato di new york (pdf). chiamare il (800) 342-3736 for free language assistance.
• Russian: ЗАЯВЛЕНИЕ ДЛЯ ПОДАЧИ ВНЕШНЕЙ АПЕЛЛЯЦИИ В ШТАТЕ НЬЮ-ЙОРК (pdf). Чтобы получить бесплатные переводческие услуги, позвоните, пожалуйста, по следующему (но36-3) (но36-3)Korean
• : 뉴욕 주 외부 이의 제기 신청서 (pdf). 전화 (800) 342-3736 로무료언어지원서비스를요청하십시오

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