Current through Register Vol. 47, No. 12, March 26, 2025
(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.
(b) The commissioner and
superintendent shall develop a separate form and instructions for an enrollee's
health care provider to request an external appeal in connection with a
retrospective adverse utilization review determination pursuant to section
4904 of the
Public Health Law. The form must include 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 the health care provider to be eligible for an external
appeal.
