As soon as you are aware of a recommended hospitalization or outpatient treatment for any of the Plan’s Managed enefits Programs, you should telephone the Managed Benefits Coordinator (referred to hereafter as the Coordinator). Their contact information can be found in Appendix A. When you call, please have the following information available:

• Your name, address, and social security or alternate ID number;
• Patient’s name, address, social security or alternate ID number, and age;
• Doctor’s name, address, and phone number, if appropriate;
• Admitting hospital name and phone number, if appropriate;
• Employer’s name and Claims Administrator’s name;
• Medical condition and planned procedure, if known.

As soon as the Coordinator receives notice, the following actions happen:

1. Pre-Certification Process
   • a. All requests for pre-certification of Hospital admissions or other services are reviewed to determine Medical Necessity (including the appropriateness of the proposed level of care and/or provider) and to determine whether the care is Experimental and/or Investigational. The initial review is performed by a nurse. If the nurse determines that
     the proposed care is Medically Necessary and not Experimental and/or Investigational, she will authorize the care. (Authorized care is still subject to all Plan benefit provisions such as deductibles, co-insurance/co-payments and annual/lifetime maximums.)
   • If the nurse determines that the proposed care is not Medically Necessary or is Experimental and/or Investigational or that further evaluation is needed, she will refer the case to a clinical peer reviewer (defined as a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid nonrestricted
     license, certification or registration or, where no provision for a license, certification 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.). Failure to make a determination within the time periods required by Article 49 of the New York Insurance law will be deemed to be an adverse determination that is subject to an internal appeal.
   • b. Notice of an approval of proposed care or an adverse determination that proposed care is not Medically Necessary or is Experimental and/or Investigational will be provided to you and your authorized designee, and your provider, by telephone and in writing, within 3 business days following receipt of all information necessary to make the decision.
   • c. The notice of an adverse determination will include the reasons, including clinical rationale, for our determination. The notice will also advise you of your right to a review of the adverse determination, give instructions for initiating standard, expedited and external appeals, and specify that you may request a copy of the
     clinical review criteria used to make the adverse determination. The notice will also specify additional information or documentation, if any, needed for us to make a Level One internal appeal determination.
   • d. If, prior to making an adverse determination, no attempt was made to consult with the provider who requested the prior authorization, the provider may request reconsideration by the same clinical peer reviewer who made the adverse determination. The reconsideration will take place within one (1) business day of the request for reconsideration, in consultation with the requesting provider. If the adverse determination is upheld, notice will be given to the provider, by telephone and in writing, within three (3) business days from the date of reconsideration. All of the information described in paragraph 1.c. above will be included in this notice.
2. Concurrent review process.
   • a. When you are receiving services that are subject to concurrent review, a nurse will periodically assess the Medical Necessity, level of care, and Experimental and/or Investigational nature of services you receive throughout the course of treatment.
   • b. Once a case is assigned for concurrent review, a nurse will determine whether the services being received are Medically Necessary, at the appropriate level and not Experimental and/or Investigational. If so, the nurse will authorize the care. If the nurse determines that the care is not Medically Necessary or is Experimental and/or
     Investigational or that further evaluation is needed, the nurse will refer the case to a clinical peer reviewer (defined in paragraph 1.a. above). Failure to make a determination within the time periods required by article 49 of the New York Insurance Law will be deemed to be an adverse determination that is subject to Level One internal appeal (described in paragraph 4. below).
   • Your provider will be notified of the concurrent review decision, by telephone and in writing, within one (1) business day following our receipt of all information or documentation needed for the review.
   • If care is authorized, the notice will identify the number of approved services, the new total of approved services, the date services may begin, and the date of the next scheduled concurrent review of the case. If care is not authorized, the notice of any adverse determination will include the reasons, including clinical rationale, for our determination. The notice will advise you of your right to a review of the adverse determination, give instructions for initiating standard, expedited, and external appeals, and specify that you may request a copy of the clinical review criteria used to make the adverse determination. The notice will also specify additional information or documentation needed, if any, for us to make a Level One internal appeal determination.
   • e. If, prior to making an adverse determination, no attempt was made to consult with the provider who requested the prior authorization, the provider may request reconsideration by the same clinical peer reviewer who made the adverse determination. The reconsideration will take place within one (1) business day of the request for reconsideration, in consultation with the requesting provider. If the adverse determination is upheld, notice will be given to the provider, by telephone and in writing, within one (1) business day from the date of reconsideration. All of the information described in paragraph 2.d. above will be included in this notice.
3. Retrospective review process.
   • a. At the option of the Plan and the Utilization Review Manager, a nurse may review the Medical Necessity and the Experimental and/or Investigational nature of services, which are subject to utilization review after the care has been received. If the nurse determines that the care you received was Medically Necessary and not Experimental and/or Investigational, the nurse will authorize benefits. If the nurse determines that the care was not Medically Necessary or was Experimental and/or Investigational, the nurse will refer the case to a clinical peer reviewer (defined in
     paragraph 1.a. above). Failure to make a determination within the time periods required by Article 49 of the New York Insurance Law will be deemed to be an adverse determination that is subject to Level One internal appeal (described in
     paragraph 4. below).
   • b. You or your authorized designee and your provider will be notified of the retrospective review determination, in writing, within 30 calendar days from our review of all information or documentation needed for the review.
   • c. The notice of any adverse determinations will include the reasons, including clinical rationale, for our determination. The notice will advise you or your right to request a review of the adverse determination, give instructions for initiating standard, expedited, or external appeals, and specify that you or your authorized designee may request a copy of the clinical review criteria used by us to make the adverse determination. The notice will also specify additional information or documentation needed, if any, for us to make a Level One internal appeal determination.
   • d. The provider who rendered care for which benefits are denied may request a Level One internal appeal of the retrospective adverse determination on your behalf (even if not authorized in writing by you to act as you designee).

HOW DO I APPEAL A MANAGED DECISION I DISAGREE WITH?
Review of adverse determinations.

1. 1. Request for Level One Internal Appeal.
   • a. 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.
   • b. 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. 2. Standard Level One Internal Appeal.
   • a. We will acknowledge your Level One Internal Appeal in writing, within five (5) business days after receiving it.
   • b. 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.
   • c. 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.
3. d. 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.
4. Expedited Level One Appeal.
   • a. 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.
   • b. 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.
   • c. 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.
   • d. 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.
5. Level Two Internal Appeals.
   • a. 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.
   • b. 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.
   • d. 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.

   • e. 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.

1. What is an External Appeal?
   • a. 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.
   • b. 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.
   • c. 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.
2. Eligibility for an External Appeal.
   To be eligible for an external appeal:
   • a. 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.
   • b. If both you and your health plan agree to waive the internal appeal process, the health plan will confirm the agreement in writing.
   • c. 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.
   • d. 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.
   • e. 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.
   • f. 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.

3. What About the Second Level of Internal Appeal to my Health Plan Appeal Committee?
   • a. 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.
   • b. 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.
4. 4. Am I Eligible for an External Appeal if I am Covered by Medicare or Medicaid?
   • a. 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.
   • b. 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.
   • c. 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.
5. Eligibility for an Expedited (Fast-Tracked) External Appeal.
   • a. 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.
6. How Long an External Appeal Will Take?
   • a. 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.
   • b. 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.
7. The Cost to You for an External Appeal.
   The Health Plan charges a fee of $50.00 for an external appeal.
   • a. 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.
   • b. 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.
   • c. Only checks or money orders, made payable to your health plan, will be accepted.
   • d. If the external appeal agent overturns your health plan’s determination, the fee will be
     refunded to you.
8. When Information May be Submitted to the External Appeal Agent.
   • a. 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.
   • b. The Health Plan must send any medical and treatment record either it, or its UR vendors, have to the external appeal agent.
   • c. 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.
   • d. 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.
9. What Happens When an External Appeal Agent Makes a Decision?
   • a. 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.
   • b. 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.
   • c. 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.