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 98-2.3 - Standard description of the external appeal process

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Health care plans shall provide
					 enrollees, and upon request, health care providers, with a copy of the standard
					 description of the external appeal process developed jointly by the
					 commissioner and superintendent, including a form and instructions for
					 enrollees to request an external appeal. The standard description, request form
					 and instructions for the external appeal process developed jointly by the
					 commissioner and superintendent shall include, but not be limited to:
(1) a statement of the enrollee's right to an
					 external appeal of health care services denied pursuant to a utilization review
					 determination by the enrollee'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 Public Health Law and Insurance
					 Law and the following:
(i) Medicare cannot be
					 the enrollee's only source of health services; and
(ii) enrollees 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 enrollees 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 enrollees 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
					 enrollee's attending physician to complete;
(6) notification that requests for external
					 appeal must be accompanied by the appropriate fee, as determined by the
					 enrollee'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 enrollee's health care plan to send the enrollee's medical and treatment
					 records to the certified external appeal agent, provided that the certified
					 external appeal agent may request additional information from the enrollee, the
					 enrollee's health care provider or the enrollee's health care plan at any
					 time;
(8) a description of the
					 right of the enrollee and the enrollee'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 enrollee
					 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, provided that the external
					 appeal agent has not yet rendered a determination on the appeal;
(9) a description of the process for
					 notifying the enrollee and the enrollee'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 enrollee or health care provider has questions;
(12) notification that an enrollee or a
					 person authorized pursuant to law to consent to health care for the enrollee
					 must sign the request and consent to the release of medical and treatment
					 records for an enrollee to be eligible for an external appeal; and
(13) a signature line for the enrollee'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 enrollee's external appeal, and
					 the expiration date of the authority to release the enrollee'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.