Current through Register Vol. 46, No. 39, September 25, 2024
(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 superintendent and commissioner, the requests
shall be screened by the superintendent to determine eligibility for external
appeal pursuant to the criteria detailed in section
4910
(b) of the Insurance Law and section 4910.2
of the Public Health Law and the following:
(1) the insured 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 insured
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
title XVIII and title 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 insured 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 insured 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
insured, or a person authorized pursuant to law to consent to health care for
the insured, authorizing release of medical and treatment information;
and
(vi) in the case of a
retrospective adverse determination, if the insured's health care provider is
requesting an external appeal, and the insured's acknowledgment of the external
appeal request and consent for the release of the insured'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 insured's health care provider to
the insured notifying the insured that an external appeal of a retrospective
adverse determination has been requested and that the insured's medical records
will be released to a certified external appeal agent;
(4) as applicable, the insured's attending
physician attestation is fully and appropriately completed by the attending
physician in the form and manner prescribed by the superintendent and
commissioner, or the insured has indicated that the attending physician
attestation has been transmitted to the insured'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
insured's 45-day time frame for initiation of an external appeal request
pursuant to section
4914
(b)(1) of the Insurance 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 insured participate in a clinical trial, the attending
physician attests that:
(i) the insured has a
life-threatening or disabling condition or disease, as defined in subdivision
(g-1) of section
4900 of the
Insurance Law;
(ii) the insured
meets the eligibility criteria for the clinical trial;
(iii) the clinical trial is open to the
insured; and
(iv) the insured 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 superintendent and
commissioner, to the superintendent within 45 days from the date the insured
or, for provider initiated retrospective appeals, the insured's health care
provider, 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. Unless otherwise
demonstrated, it shall be presumed that the insured, or the insured'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 insured's health care plan or
the insured'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 insured and the insured'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 insured 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
410.6(e)(1) of
this Part;
(3) for purposes of
notifying the insured's health care plan, a copy of the insured's signed
release of medical and treatment information, completed in a manner as
prescribed jointly by the superintendent and commissioner 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 insured'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 insured or, in the case of a provider initiated retrospective appeal,
the insured'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 insured or, in the case
of a provider initiated retrospective appeal, the insured's health care
provider, by the superintendent, with notification to the insured'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.
