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 98-2.11 - Enrollee rights and responsibilities

Universal Citation: 10 NY Comp Codes Rules and Regs § 98-2.11

Current through Register Vol. 47, No. 12, March 26, 2025

(a) Enrollees shall be responsible for:

(1) exhausting the health care plan's internal appeal process under section 4904 of the Public Health Law, provided however, that if a health care plan has two levels of internal appeals, the enrollee must only exhaust the first level of appeal. In the alternative, the enrollee and the enrollee's health care plan may jointly agree to waive the internal appeal process;

(2) ensuring that requests for external appeals are filed and completed within the time frames provided for in paragraph (4) of this subdivision, except in the case of transmittal of medical and treatment records, which shall be the responsibility of the enrollee's health care plan;

(3) as applicable, providing the attending physician with the documents necessary to complete the physician attestation component of the external appeal request, and, as necessary, providing evidence to the superintendent that such has occurred; and

(4) ensuring that, to the extent possible, all supporting documentation, including but not limited to diagnostic test results and medical literature, is submitted to the assigned certified external appeal agent within the earlier of:
(i) 45 days from the date of the enrollee's receipt of a final adverse determination notice or within 45 days of receiving 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; or

(ii) prior to the date the external appeal determination is finalized by the certified external appeal agent; and

(5) responding to the superintendent's requests for information concerning an incomplete external appeal request in a timely manner.

(b) Enrollees whose health benefits are provided through both titles XVIII and XIX of the Federal Social Security Act are eligible to request an external appeal only for those health care services covered through title XIX.

(c) Enrollees whose health benefits are provided through title XIX of the Federal Social Security Act and who request an external appeal pursuant to title II of article 49 of the Public Health Law or the Insurance Law may additionally apply to the Department of Health for a fair hearing pursuant to the terms and within the time frames prescribed by sections 22 and 364-j of the Social Services Law and applicable regulations. Pursuant to section 4910 (4) of the Public Health Law and section 4910 (d) of the Insurance Law, a fair hearing determination prevails over an external appeal determination; therefore, any appeal for which a determination has been made pursuant to the fair hearing process shall not be considered for external appeal.

(d) Enrollees, except for those whose health benefits are provided through title XIX of the Federal Social Security Act and title 1-A of article 25 of the Public Health Law, are responsible for enclosing a fee with the request for an external appeal to the superintendent in accordance with the fee prescribed by the enrollee's health care plan. The enrollee is responsible for requesting a waiver of the fee requirement from the health care plan if such fee will pose a financial hardship for the enrollee. Enrollees shall not be responsible for paying a fee for any external appeal requested by a health care provider relative to a retrospective adverse determination.

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