N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 98-2.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 98-2.3 - Standard description of the external appeal process

(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.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 98-2.3