Consumers who are enrolled in New York State regulated health plans such as fully-insured commercial plans, qualified health plans, or Medicaid managed care plans, have the right to appeal to the New York State Department of Financial Services (DFS) when their plan issues a final denial for health care services as not medically necessary, experimental/investigational or as an out-of-network referral/service. This appeal is known as an External Appeal. External Appeals are assigned to an Appeal Agent, an independent medical review organization whose doctors decide whether the plan’s decision was correct or should be overturned based on the enrollee’s medical records and standard medical practice.
DFS now publishes an External Appeals Searchable Database. The database includes summaries of recent decisions and provides references to medical literature that the Appeal Agent relied on to reach its decision. Consumers can use the medical literature cited in their own appeals.
Consumers can search External Appeal decisions in the database by the following categories: Diagnosis, Treatment, Health Plan, Appeal Type, Gender, Age Range, Decision Year, Appeal Agent or Case Number. Consumers can also search by keywords that may appear in the text of the summaries, such as type of cancer or a drug name.
A link to the External Appeal Database can be found below along with the application and information on how to file an External Appeal. If you need assistance in understanding the external appeals process or filing an External Appeal, please contact CHA at 888-614-5400.