Current through Register Vol. 47, No. 12, March 26, 2025
(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 commissioner and superintendent, the requests
shall be screened by the superintendent to determine eligibility for external
appeal pursuant to the criteria detailed in section
4910
(2) of the Public Health Law and section
4910
(b) of the Insurance Law and the following:
(1) The enrollee 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 enrollee
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
titles XVIII and 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 enrollee 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 enrollee 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
enrollee, or a person authorized pursuant to law to consent to health care for
the enrollee, authorizing release of medical and treatment information;
and
(vi) in the case of a
retrospective adverse determination, if the enrollee's health care provider is
requesting an external appeal and the enrollee's acknowledgment of the external
appeal request and consent for release of the enrollee'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 enrollee's health care provider to
the enrollee notifying the enrollee that an external appeal of a retrospective
adverse determination has been requested and that the enrollee's medical
records will be released to a certified external appeal agent.
(4) As applicable, the enrollee's
attending physician attestation is fully and appropriately completed by the
attending physician in the form and manner prescribed by the commissioner and
superintendent, or the enrollee has indicated that the attending physician
attestation has been transmitted to the enrollee'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
enrollee's 45-day time frame for initiation of an external appeal request
pursuant to section
4914
(2)(a) of the Public Health 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 enrollee participate in a clinical trial, the attending
physician attests that:
(i) the enrollee has
a life-threatening or disabling condition or disease, as defined in subdivision
7-a of section
4900 of the
Public Health Law;
(ii) the
enrollee meets the eligibility criteria for the clinical trial;
(iii) the clinical trial is open to the
enrollee; and
(iv) the enrollee 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 commissioner and
superintendent, to the superintendent within 45 days from the date the enrollee
or, for provider initiated retrospective appeals, the enrollee's health care
provider, 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. Unless otherwise
demonstrated, it shall be presumed that the enrollee, or the enrollee'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.
(b) Screening
of expedited appeals shall be initiated by the superintendent within 24 hours
of receipt of the request. Screening of standard appeals shall be initiated by
the superintendent within five business days of receipt of the
request.
(c) In the event that
additional information is required to process a request, the superintendent
shall contact the initiator of the request, the enrollee's health care plan or
the enrollee's attending physician, as appropriate, by the most efficient means
available, to request the necessary information.
(d) A copy of appropriately completed
requests for appeals of final adverse utilization review determinations made by
entities certified under article 44 of the Public Health Law that are
determined to be eligible for external appeal shall be transmitted to the
commissioner immediately after assignment to a certified external appeal
agent.
(e) The superintendent shall
notify the enrollee and the enrollee's health care plan if a request is
determined to be eligible for external appeal within seven days of receipt of a
complete request for a standard appeal and within 48 hours of receipt of a
complete request for an expedited appeal. Such notification shall include:
(1) identification of the certified external
appeal agent assigned to the appeal;
(2) notification to the enrollee of any
unavoidable material affiliations concerning the certified external appeal
agent assigned to the appeal, including a brief explanation of the nature of
the material affiliation(s) pursuant to section
98-2.6(e)(1) of
this Subpart;
(3) for purposes of
notifying the enrollee's health care plan, a copy of the enrollee's signed
release of medical and treatment information, completed in a manner as
prescribed jointly by the commissioner and superintendent and 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; and
(4) for purposes of notifying the enrollee's
health care plan, as applicable, a copy of the attending physician's
attestation.
(f) If a
fee is submitted and the health care plan's determination is upheld by the
external appeal agent, the superintendent shall forward the fee to the health
care plan within seven days of receipt of the external appeal agent's
determination.
(g) If a fee is
submitted and the health care plan's determination is overturned in whole or in
part by the external appeal agent, the superintendent shall return the fee to
the enrollee or, in the case of a provider initiated retrospective appeal, the
enrollee's health care provider, within seven days of receipt of the external
appeal agent's determination.
(h)
Those requests determined to be ineligible for external appeal shall be
returned to the enrollee or, in the case of a provider initiated retrospective
appeal, the enrollee's health care provider, by the superintendent, with
notification to the enrollee's health care plan and attending physician, as
appropriate, accompanied by an explanation as to why the request was determined
to be ineligible for external appeal within seven days of receipt of a complete
request for a standard appeal and within 48 hours of receipt of a complete
request for an expedited appeal.
