For the seriously ill and their caregivers
If Your Request is Denied
If your claim or your request for a specific treatment is denied, you have appeal rights mandated in the law.
A grievance can be filed for any determination other than a denial based on the policy provisions excluding services which are deemed not medically necessary, experimental or investigational.
For more information on filing a grievance, please select this link.
Utilization Review Appeal
A utilization review appeal can be filed for any denial of care that the HMO or insurer has decided is experimental, investigational or not medically necessary.
For more information on filing a utilization review appeal, please select this link.
External Review/External Appeal
An external appeal is a request made to the state for an independent review when your health plan denies health care services as not medically necessary, experimental, or investigational. 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.
An external appeal is available if you have been denied coverage for participation in a clinical trial.
For more information on filing an external appeal, please select this link.
Complaints to the New York State Department of Financial Services
A complaint can be filed directly to the New York State Department of Financial Services if you have a specific problem with an insurance company, broker, agent or adjuster.
For more information on filing a complaint, please select this link.
HMO - Quality of Care Complaints
A complaint can be filed directly to the New York State Department of Health if it is complaint against an HMO regarding quality of care.
Send a written complaint to:
New York State Department of Health
Office of Managed Care
Bureau of Managed Care Certification and Surveillance - Complaint Unit
Corning Tower, Room 1911
Albany, NY 12237