New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XVIII - External Appeals Of Adverse Determinations Of Health Care Plans › Part 410 - External Appeals Of Adverse Determinations Of Health Care Plans › Section 410.3 - Standard description of the external appeal process

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Health care plans shall provide insureds,
				and upon request, health care providers, with a copy of the standard
				description of the external appeal process developed jointly by the
				superintendent and commissioner, including a form and instructions for insureds
				to request an external appeal. The standard description, request form and
				instructions for the external appeal process developed jointly by the
				superintendent and commissioner shall include, but not be limited to:
(1) a statement of the insured's right to an
				external appeal of health care services denied pursuant to a utilization review
				determination by the insured's health care plan on the basis that the services
				are not medically necessary or that the services are experimental or
				investigational;
(2) a description
				of the eligibility criteria for an external appeal pursuant to section 4910  of the Insurance Law and Public Health
				Law and the following:
(i) Medicare cannot be
				the insured's only source of health services; and
(ii) insureds receiving benefits under both
				Medicaid and Medicare are eligible for the external appeal process only for
				denials of benefits that are covered under Medicaid;
(3) notification that insureds receiving
				benefits under Medicaid may also file a complaint through the fair hearing
				process and that the determination in the fair hearing process will be the one
				that controls;
(4) notification of
				the time frames within which the certified external appeal agent must make a
				determination on expedited and nonexpedited external appeals;
(5) notification that insureds requesting an
				expedited external appeal or an external appeal of a health care plan's denial
				because the requested health care service is considered to be experimental or
				investigational should forward the attending physician's attestation to the
				insured's attending physician to complete;
(6) notification that requests for an
				external appeal must be accompanied by the appropriate fee, as determined by
				the insured's health care plan, or a statement that a waiver of the fee has
				been requested, in order to be eligible for an external appeal;
(7) a description of the responsibility of
				the insured's health care plan to send the insured's medical and treatment
				records to the certified external appeal agent, provided that the certified
				external appeal agent may request additional information from the insured, the
				insured's health care provider or the insured's health care plan at any
				time;
(8) a description of the
				right of the insured and the insured's health care provider to submit
				information to the certified external appeal agent, regardless of whether the
				agent has requested any information, within 45 days from when the insured
				received notice that the health care plan made a final adverse determination or
				within 45 days from when the insured received a letter from the health care
				plan affirming that both the insured and the insured's health care plan jointly
				agreed to waive the internal appeal process, provided that the external appeal
				agent has not yet rendered a determination on the appeal;
(9) a description of the process for
				notifying the insured and the insured's health care plan of the certified
				external appeal agent's determination;
(10) instructions for submitting the request
				for external appeal to the superintendent;
(11) instructions for contacting the State if
				the insured or health care provider has questions;
(12) notification that an insured or a person
				authorized pursuant to law to consent to health care for the insured must sign
				the request and consent to the release of medical and treatment records for an
				insured to be eligible for an external appeal; and
(13) a signature line for the insured's
				consent to the release of his or her medical and treatment records, including
				HIV, mental health and alcohol and drug abuse records, to the certified
				external appeal agent assigned to review the insured's external appeal, and the
				expiration date of the authority to release the insured's medical and treatment
				records in accordance with section 2782  of the Public Health Law for
				confidential HIV related information and sections 33.13 and
				33.16  of the Mental Hygiene Law for mental
				health related information.