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 410.7 - 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 superintendent and commissioner, the requests
				shall be screened by the superintendent to determine eligibility for external
				appeal pursuant to the criteria detailed in section 4910 (b)  of the Insurance
				Law and section 4910.2 of the Public Health Law and the following:
(1) the insured 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 insured
				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
				title XVIII and title 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 insured 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 insured 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
				insured, or a person authorized pursuant to law to consent to health care for
				the insured, authorizing release of medical and treatment information;
				and
(vi) in the case of a
				retrospective adverse determination, if the insured's health care provider is
				requesting an external appeal, and the insured's acknowledgment of the external
				appeal request and consent for the release of the insured'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 insured's health care provider to
				the insured notifying the insured that an external appeal of a retrospective
				adverse determination has been requested and that the insured's medical records
				will be released to a certified external appeal agent;
(4) as applicable, the insured's attending
				physician attestation is fully and appropriately completed by the attending
				physician in the form and manner prescribed by the superintendent and
				commissioner, or the insured has indicated that the attending physician
				attestation has been transmitted to the insured'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
				insured's 45-day time frame for initiation of an external appeal request
				pursuant to section 4914 (b)(1)  of the
				Insurance 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 insured participate in a clinical trial, the attending
				physician attests that:
(i) the insured has a
				life-threatening or disabling condition or disease, as defined in subdivision
				(g-1) of section 4900  of
				the Insurance Law;
(ii) the insured
				meets the eligibility criteria for the clinical trial;
(iii) the clinical trial is open to the
				insured; and
(iv) the insured 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 superintendent and
				commissioner, to the superintendent within 45 days from the date the insured
				or, for provider initiated retrospective appeals, the insured's health care
				provider, 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. Unless otherwise
				demonstrated, it shall be presumed that the insured, or the insured'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.