State agency ยท New York State Department of Financial Services
New York Department of Financial Services: external appeal
If a New York insurer or health maintenance organization denies care as not medically necessary, experimental or out of network, you can ask the state for an external appeal. You have 4 months from the plan's final decision.
Know before you go
The application must reach the department within 4 months of the plan's final decision. A second-level internal appeal is optional and does not extend that time. The page also lists some surprise-bill questions the department will review. It does not say which plans cannot use the program, so confirm with the department that your plan is covered.
- Cost
- The plan may charge up to $25 per appeal and no more than $75 in a plan year. The page says the fee is waived for people on Medicaid, Child Health Plus or Family Health Plus or if it is a hardship, and it is returned if the denial is overturned.
- Where
- New York
- How to start
- Finish the plan's internal appeal (or have it waived), then send the external appeal application to the department. The department's research found that filing online needs an account on its portal and that some forms need a signature.
- Phone
- (800) 400-8882, as printed on the provider's page
- Have ready
- The plan's final adverse determination letter; The external appeal application; Your doctor's attestation form for your appeal type; Your insurance card
Where this comes from
- Provider
- New York State Department of Financial Services
- Source we read
- https://www.dfs.ny.gov/complaints/file_external_appeal
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy