New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.7 - Screening of requests for external appeal

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Requests for external appeals shall be
					 submitted to the superintendent. Upon receipt of such requests completed in the
					 form and manner prescribed by the commissioner and superintendent, the requests
					 shall be screened by the superintendent to determine eligibility for external
					 appeal pursuant to the criteria detailed in section 4910 (2)  of the Public
					 Health Law and section 4910 (b)  of the Insurance
					 Law and the following:
(1) The enrollee
					 submitting the request or on whose behalf a request for external appeal was
					 submitted, or in the case of a retrospective adverse determination, on whose
					 behalf a health care service is delivered, is not covered exclusively by title
					 XVIII of the Federal Social Security Act.
(2) If the enrollee submitting the request or
					 on whose behalf a request for external appeal was submitted, or in the case of
					 a retrospective adverse determination, on whose behalf a health care service is
					 delivered, is receiving benefits under both titles XVIII and XIX of the Federal
					 Social Security Act, the health care service being requested is a covered
					 benefit under title XIX.
(3) The
					 request is substantially complete as appropriate for the type of determination
					 to be appealed and contains the following:
(i)
					 a copy of the final adverse determination letter from the health care plan
					 notifying the enrollee that their request for health care services was denied
					 on appeal; or
(ii) a copy of a
					 letter from the health care plan to the enrollee indicating a joint agreement
					 to waive any internal appeal offered by the health care plan; or
(iii) in the case of a retrospective adverse
					 determination, a copy of the final adverse determination letter from the health
					 care plan;
(iv) payment of a fee,
					 if applicable, or a statement that a waiver of the fee has been
					 requested;
(v) the signature of the
					 enrollee, or a person authorized pursuant to law to consent to health care for
					 the enrollee, authorizing release of medical and treatment information;
					 and
(vi) in the case of a
					 retrospective adverse determination, if the enrollee's health care provider is
					 requesting an external appeal and the enrollee's acknowledgment of the external
					 appeal request and consent for release of the enrollee's medical records to a
					 certified external appeal agent is obtained at the time health care services
					 are provided, a copy of a letter sent by the enrollee's health care provider to
					 the enrollee notifying the enrollee that an external appeal of a retrospective
					 adverse determination has been requested and that the enrollee's medical
					 records will be released to a certified external appeal agent.
(4) As applicable, the enrollee's
					 attending physician attestation is fully and appropriately completed by the
					 attending physician in the form and manner prescribed by the commissioner and
					 superintendent, or the enrollee has indicated that the attending physician
					 attestation has been transmitted to the enrollee's attending physician. An
					 application shall not be considered incomplete or untimely solely on the basis
					 of failure by the attending physician to submit such documentation within the
					 enrollee's 45-day time frame for initiation of an external appeal request
					 pursuant to section 4914 (2)(a)  of the Public
					 Health Law, provided however, the application will not be forwarded to an
					 external appeal agent until the attestation is submitted.
(5) If the attending physician is
					 recommending that the enrollee participate in a clinical trial, the attending
					 physician attests that:
(i) the enrollee has
					 a life-threatening or disabling condition or disease, as defined in subdivision
					 7-a of section 4900  of the Public Health Law;
(ii) the enrollee meets the eligibility
					 criteria for the clinical trial;
(iii) the clinical trial is open to the
					 enrollee; and
(iv) the enrollee has
					 been or will likely be accepted into the clinical trial.
(6) The external appeal request was
					 submitted, in the form and manner prescribed by the commissioner and
					 superintendent, to the superintendent within 45 days from the date the enrollee
					 or, for provider initiated retrospective appeals, the enrollee's health care
					 provider, received notice that the health care plan made a final adverse
					 determination or within 45 days from when the enrollee received a letter from
					 the health care plan affirming that both the enrollee and the enrollee's health
					 care plan jointly agreed to waive the internal appeal process. Unless otherwise
					 demonstrated, it shall be presumed that the enrollee, or the enrollee's health
					 care provider for provider initiated retrospective appeals, received the notice
					 of final adverse determination or letter agreeing to waive the internal appeal
					 process within eight days of the date on the notice of final adverse
					 determination or the date on the letter agreeing to waive the internal appeal
					 process.