How to appeal a health insurance denial in New York
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. New York lets you ask an independent reviewer to decide, through New York State Department of Financial Services. The deadline to ask: within 4 months from the date of the final adverse determination from your internal appeal, or from the waiver of the internal appeal process (providers appealing on their own behalf: 60 days).
Does this apply to you? State external review covers plans regulated by New York: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in New York
Within 4 months from the date of the final adverse determination from your internal appeal, or from the waiver of the internal appeal process (providers appealing on their own behalf: 60 days)
A decision comes within 72 hours (24 hours for a non-formulary drug), even if not all medical records have been sent. You can request expedited internal and external appeals at the same time. Most expedited appeals need a physician attestation, and services already received cannot be expedited.
Your health plan may charge $25 per appeal (no more than $75 per plan year). The fee is waived for Medicaid, Child Health Plus and Family Health Plus members or for hardship, and refunded if the denial is overturned.
State-regulated plans (insurance bought in New York or through an employer that buys insurance). Self-funded employer plans use the federal process.
File with DFS through the DFS Portal (choose 'DFS Portal Login'), or send the fillable PDF by email to earesponse@dfs.ny.gov, fax 800-332-2729 or certified mail. A signed patient consent form is required. A second-level internal appeal is optional, and filing one does not extend the 4 months from the first appeal decision. Besides medical-necessity and experimental denials, out-of-network, formulary-exception and No Surprises Act denials also qualify. DFS external appeal help line: 800-400-8882.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in New York?
Within 4 months from the date of the final adverse determination from your internal appeal, or from the waiver of the internal appeal process (providers appealing on their own behalf: 60 days)
Can I get a fast external review in New York?
A decision comes within 72 hours (24 hours for a non-formulary drug), even if not all medical records have been sent. You can request expedited internal and external appeals at the same time. Most expedited appeals need a physician attestation, and services already received cannot be expedited.
Does external review cost anything in New York?
Your health plan may charge $25 per appeal (no more than $75 per plan year). The fee is waived for Medicaid, Child Health Plus and Family Health Plus members or for hardship, and refunded if the denial is overturned.
Do New York’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- DFS: New York State External Appeal
You must send an appeal application to DFS within 4 months from the date of the final adverse determination from your internal appeal with the health plan, or waiver of the internal appeal process.
- DFS: New York State External Appeal (Fees)
Health plans may charge a $25.00 fee per appeal (but not more than $75.00 in a single plan year.)
- N.Y. Insurance Law 4914
The insured shall have four months to initiate an external appeal
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.