Appeals Process

HOW DO I APPEAL A MANAGED DECISION I DISAGREE WITH?

Review of adverse determinations.

1.Request for Level One Internal Appeal.

  • Appeals Procedure Form
  • Caremark Claim Form
  • Caremark Mail order Form
  • Change Form
  • HIPPA Release Form
  • Indecs Claim Form
  • You, your authorized designee, and, in a retrospective review case, your health care
    provider may request a Level One internal appeal of an adverse determination, verbally
    or in writing, within 60 business days from the date that you receive notice of the adverse
    determination. To request a Level One Internal Appeal verbally, you may call 1-800-764-
    3433. To submit a written request for a Level One Internal Appeal, you may write to
    HealthCare Strategies, Inc., 9841 Broken Land Parkway, Suite 315, Columbia, Maryland
    21046.
  • Your case will differ, depending upon the urgency of the case. In most cases, a standard
    Level One Internal Appeal, described below, will be appropriate. In “urgent
    cases,” an expedited Level One Internal Appeal is available; the expedited Level
    One Internal Appeal process is described after standard Level One Internal
    Appeal below.

2. Standard Level One Internal Appeal.

  • We will acknowledge your Level One Internal Appeal in writing, within five (5) business
    days after receiving it.
  • When one or more Level One Internal Appeals are received (for example, you submit an
    appeal, then your health care provider submits an appeal on your behalf), a single Level
    One internal Appeal will be conducted by a clinical peer reviewer (a physician who
    possesses a current and valid non-restricted license to practice medicine, or a heath care
    professional other than a licensed physician who, were applicable, possesses a current
    and valid non-restricted license, certification, or registration or, where no provision for a
    license, certificate, or registration exists, is credentialed by the national accrediting body
    appropriate to the profession and is in the same profession/specialty as the health care
    provider who typically manages the medical condition), who did not make the initial
    adverse determination.
  • The clinical peer reviewer will render a determination within 30 calendar days after
    receipt of all necessary information. Written notice of the determination will be provided
    to you and any other qualified party who submitted a Level One Internal Appeal within
    two (2) business days after the determination is made, but in no event later than 30
    calendar days after receiving all necessary information. Failure to render a determination
    within the time periods required by Article 49 of the New York Insurance Law will be
    deemed to be a reversal of the initial adverse determination.
  • The notice will include detailed reasons and the clinical rational for the determination. If
    the determination is adverse, the notice will describe the procedure for filing an external
    appeal of the adverse determination. The external appeal process is described in
    paragraph “o” below. Note – If you submit a Level Two Internal Appeal, the review
    appeal may take longer than the 45-day time frame for requesting an external appeal
    through New York State, which begins on the date you receive the final adverse
    determination notice upon completion of Level One Internal Appeal.

Expedited Level One Appeal.

  • For cases involving a prospective or concurrent (but not retrospective) review decision
    (such as the review of continued or extended health care services; additional services
    rendered in the course of continued treatment; or any other issue with respect to which a
    provider requests an immediate review), you, your authorized designee, or a provider
    may request an expedited Level One Internal Appeal of the initial adverse determination.
  • When a request for expedited Level One Internal Appeal is received, the appeal will be
    conducted by a clinical peer reviewer who did not render the initial adverse
    determination. The Plan’s Managed Benefits Program Coordinator will provide
    reasonable access to the clinical peer reviewer assigned to the appeal, within one (1)
    business day following receipt of notice of the request for appeal, to ensure that all
    relevant information is available to the clinical peer reviewer. You may ask that your
    provider and the clinical peer reviewer exchange information by telephone or fax.
  • Within 48 hours of review by us of all information needed for the appeal, the clinical peer
    reviewer will decide the expedited Level One Internal Appeal. Failure to render a
    determination within the time periods required by Article 49 of the New York Insurance
    Law will be deemed to be a reversal of the initial adverse determination.
  • Notice will be provided to you and the provider, by telephone and in writing, within 24
    hours of the determination. The notice will include all of the information described and
    enclosed in a notice of standard Level One Internal Appeal determination (see above).
    Note – If you request a Level Two Internal Appeal, the appeal may take longer than the
    45-day time frame for requesting an external appeal through New York State, which
    begins on the date you receive the final adverse determination notice upon completion of
    Level One Internal Appeal.

Level Two Internal Appeals.

  • After you receive notice of a Level One internal appeal determination, if you are still not
    satisfied, you or your authorized designee may submit a Level Two Appeal, verbally or in
    writing. (You also have an option to apply for an external appeal, see paragraph e.
    below). The Level Two internal appeal must be received by us within 60 business days
    from the date of the Level One Internal Appeal determination.
  • We will acknowledge your Level Two Internal Appeal, in writing, within 15 calendar days
    after receiving it. The acknowledgement will identify additional information, if any,
    needed for the Level Two Internal Appeal.
  • Your case will be reviewed by at least one clinical peer reviewer who did not make the
    prior determinations.
  • In “urgent cases” where a delay would significantly increase the risk to your health, we
    will make a Level Two Internal Appeal determination and call you within the lesser of two
    (2) business days or 72 hours after receiving all information needed for the review.
    Written notice of the Level Two Internal Appeal determination will also be provided within
    two (2) business days.
    In all other cases, we will make a Level Two Internal Appeal determination within 30
    business days after receiving all information needed for the review. Written notice of the
    determination will be provided to you within two (2) business days after the determination
    is made, but no later than 30 business days after receiving all necessary information.
  • The notice you receive will include detailed reasons for the Level Two Internal Appeal
    determination and, if a clinical matter is involved, the clinical rationale for the
    determination. The notice will also advise you of the right to apply for an external appeal,
    if the time frame for applying has not expired by the date of receipt of notice of an
    adverse determination on Level Two Internal Appeal.

WHAT ARE “EXTERNAL” MANAGED CARE APPEALS?

New York State Law gives you the right to an external appeal when health care services are denied by
one of the Plan’s utilization Review Agencies, on the basis that the services are not Medically Necessary
or that the services are Experimental or Investigational.
To request an external appeal you must complete a New York State External Appeal application form and
send it to the New York State Insurance Department within 45 days of when you received a notice of final
adverse determination from first level internal appeal process OR within 45 days of receiving written
confirmation from the plan that the internal appeal has been waived. If all applicable items required by
the State are not completed, your request will not be accepted.

What is an External Appeal?

  • An external appeal is a request that you make to the State of New York for an
    independent review of a denial of services by your health plan.
  • Reviews are conducted by external appeal agents that are certified by the state and have
    a network of medical experts to review your health plan’s denial of services.
  • You must complete the New York External Appeal Application which can be obtained
    from your Local School District Heath Plan Representative, any of the Plan’s Managed
    Care vendors’ utilization review firms or the Health Plan’s claims administrator. Upon
    completion, submit the application to the New York State Insurance Department to
    request an external appeal.

Eligibility for an External Appeal.

To be eligible for an external appeal:

  • You must have received a final adverse determination as a result of your health plan’s
    internal utilization review appeal process OR you and your health plan must have agreed
    to waive that appeal process. A final adverse determination is written notification from
    your health plan that your health care service has been denied through the Plan’s internal
    appeal process. Because you are entitled to an internal appeal process through the
    Plan’s utilization review agents, and then through the Health Plan’s appeal committee,
    the External Appeal Application may be made at the same time you file your second level
    appeal to the Health Plan Committee through your Local School District Health Plan
    Representative.
  • If both you and your health plan agree to waive the internal appeal process, the health
    plan will confirm the agreement in writing.
  • You must submit a request for an external appeal to the State within 45 days from when
    you received a notice of final adverse determination from your health plan OR within 45
    days of receiving written confirmation from your health plan that the internal appeal
    process has been waived.
  • If you do not file a request for an external appeal with the State within this 45-day period,
    you will not be eligible for an external appeal. As indicated in the section “How do I
    appeal a Managed Decision I disagree with?” you are entitled to an Internal Appeal by
    the Managed Care Vendor. If that Appeal results in a continued adverse decision, you
    must file a request for external appeal within 45 days of your receipt of the notice of final
    adverse determination from the plan’s first level appeal process (through the Managed
    Care Coordinator) to be eligible for an external appeal.
  • If services are denied as Experimental or Investigational, you must have a life-threatening
    or disabling condition to be eligible for an external appeal and your attending physician
    must complete the Attending Physician Attestation form and send the form to the State
    Insurance Department. This form is also available from your Local School District, the
    Plan’s Managed Care vendors or the Plan’s claims administrator.
  • If the Covered Person’s attending physician has certified that the patient has a lifethreatening
    or disabling condition or disease for which (a) standard health services or
    procedures have been ineffective or would be medically inappropriate, or (b) there does
    not exist a more beneficial standard health services or procedure covered by the health
    care plan, or (c) there exists a clinical trial, and if the covered patient’s attending
    physician, who must be a licensed, board-certified or board-eligible physician qualified to
    practice in the area of practice appropriate to treat the insured’s life-threatening or
    disabling condition or disease, has recommended either (1) a health service or procedure
    (including a pharmaceutical product) that, based on two documents from the available
    medical and scientific evidence, is likely to be more beneficial to the insured than any
    covered standard health service or procedure; or (2) a clinical trial for which the insured is
    eligible. Any physician certification must include a statement of the evidence relied upon
    by the physician in certifying his or her recommendation, and the specific health service
    or procedure recommended by the attending physician must otherwise be covered under
    the Plan except for the Plan’s determination that the health service or procedure is
    Experimental or Investigational.

You may only appeal a service or procedure that is a covered benefit under your contract. The external appeal process may not be used to expand the coverage of your Health Plan. The appeal cannot be for workers’ compensation claims or for claims under no-fault auto coverage.

2. What About the Second Level of Internal Appeal to my Health Plan Appeal Committee?

  • You are not required to seek a second level of internal appeal with your health plan in
    order to request an external appeal, although you may file one simultaneously.
  • If you seek a second level of internal appeal with your health plan, you may not have time
    to request an external appeal. You must request an external appeal within 45 days of
    receiving the determination from the health plan’s first level of internal appeal.

3. Am I Eligible for an External Appeal if I am Covered by Medicare or Medicaid?

  • You are not eligible for this external appeal process when Medicare is your only (or
    primary) source of health services. If you have coverage under Medicare, you must file a
    complaint with the federal government for denials of service.
  • If you have coverage under Medicare and Medicaid, this external appeal process may
    only be used to appeal denials of services or treatment covered by Medicaid.
  • If you have Medicaid coverage, you may also request a fair hearing. If you have
    requested an external appeal and a fair hearing, the determination in the fair hearing
    process will be the one that applies. If you have questions about the fair hearing
    process, you should contract the New York State Department of Health at 1-800-206-
    8125.

4. Eligibility for an Expedited (Fast-Tracked) External Appeal.

    • If your attending physician attests that a delay in providing the treatment or service poses
      an imminent or serious threat to your health, you may request an expedited appeal.
      When requesting an expedited appeal, make sure you give the Attending Physician
      Attestation to your doctor to complete. Your appeal will not be forwarded to the external
      appeal agent until your physician sends this attestation to the Insurance Department.

5. How Long an External Appeal Will Take?

  • Expedited Appeals:
    The external appeal agent must make a determination within three (3) days of receiving
    your request for an external review from the state.
  • Standard Appeals:
    When your appeal is not expedited, the external appeal agent must make a determination
    within 30 days of receiving your request for an external review from the state. If
    additional information is requested, the external appeal agent has five (5) additional
    business days to make a determination.

6. The Cost to You for an External Appeal.

The Health Plan charges a fee of $50.00 for an external appeal.

  • If you have coverage under Medicaid Child Health Plus, or your health plan determines
    that the fee will pose a hardship, you will not be required to pay a fee.
  • You must submit the fee with your application for an external appeal. If you fax your
    application to the Insurance Department, you must send the fee within three (3) business
    days to the Insurance Department. If the fee is not sent to the Insurance Department
    within this time frame, the external appeal agent will suspend review of your appeal until
    payment is received.
  • Only checks or money orders, made payable to your health plan, will be accepted.
  • If the external appeal agent overturns your health plan’s determination, the fee will be
    refunded to you.

7. When Information May be Submitted to the External Appeal Agent.

  • If your case is determined to be eligible for external review, you and the Health Plan will
    be notified of the certified external appeal agent assigned to review your case.
  • The Health Plan must send any medical and treatment record either it, or its UR vendors,
    have to the external appeal agent.
  • When the external appeal agent reviews your case, the agent may request additional
    information from you or your doctor. This information should be sent immediately to the
    external appeal agent.
  • You and your doctor can submit information even when the external appeal agent has not
    requested specific information. You must submit this information within 45 days from
    when your health plan made a final adverse determination or from when you and your
    health plan agreed to waive the internal appeal process.
    *** It is important to send this information immediately. Once the external appeal agent
    makes a determination or once your 45-day time period ends, you will be unable to
    submit additional information.

8. What Happens When an External Appeal Agent Makes a Decision?

  • Expedited Appeals:
    If your appeal was expedited, you and your health plan will be notified immediately by
    telephone or fax of the external appeal agent’s decision. Written notification will follow.
  • Standard Appeals:
    If your appeal was not expedited, you and your health plan will be notified in writing within
    two (2) business days of the external appeal agent’s decision.
  • Binding Decision:
    The decision of the external appeal agent is binding on you and your health plan.
    If you have any questions, please contact your Local School District Health Plan
    Administrator, the Health Plan’s claims administrator or any of the Plan’s Managed Care
    vendors whose toll-free telephone numbers are listed on your ID cards and in Appendix A
    of this document. You may also contact the New York State Insurance Department at 1-
    800-400-8882 or visit their web site at www.ins.state.ny.us.

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