Current through Register Vol. 46, No. 39, September 25, 2024
(a) Health care plans shall provide insureds,
and upon request, health care providers, with a copy of the standard
description of the external appeal process developed jointly by the
superintendent and commissioner, including a form and instructions for insureds
to request an external appeal. The standard description, request form and
instructions for the external appeal process developed jointly by the
superintendent and commissioner shall include, but not be limited to:
(1) a statement of the insured's right to an
external appeal of health care services denied pursuant to a utilization review
determination by the insured'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
Insurance Law and Public Health Law and the following:
(i) Medicare cannot be the insured's only
source of health services; and
(ii)
insureds 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 insureds 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 insureds 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
insured's attending physician to complete;
(6) notification that requests for an
external appeal must be accompanied by the appropriate fee, as determined by
the insured'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 insured's health care plan to send the insured's medical and treatment
records to the certified external appeal agent, provided that the certified
external appeal agent may request additional information from the insured, the
insured's health care provider or the insured's health care plan at any
time;
(8) a description of the
right of the insured and the insured'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 insured
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, provided that the external appeal
agent has not yet rendered a determination on the appeal;
(9) a description of the process for
notifying the insured and the insured'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 insured or health care provider has questions;
(12) notification that an insured or a person
authorized pursuant to law to consent to health care for the insured must sign
the request and consent to the release of medical and treatment records for an
insured to be eligible for an external appeal; and
(13) a signature line for the insured'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 insured's external appeal, and the
expiration date of the authority to release the insured'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 superintendent and
commissioner shall develop a separate form and instructions for an insured's
health care provider to request an external appeal in connection with a
retrospective adverse utilization review determination pursuant to section
4904 of the
Insurance Law. The form must include notification that an insured or a person
authorized pursuant to law to consent to health care for the insured 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.
