New York State External Appeal
If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network, you have the right to appeal to the Department of Financial Services (DFS) . This appeal is known as an external appeal. Health care providers also have the right to an external appeal when health care services are denied (concurrently or retrospectively).
Consumers must send an external appeal application to DFS within 4 months from the date of the final adverse determination from the first level of appeal with the health plan or the waiver of the internal appeal process. If your health plan offers a second-level internal appeal, you do not have to file one, but if you do, you must still submit an external appeal to DFS within 4 months of the first appeal decision. If DFS does not receive your application within 4 months, you will not be eligible for an external appeal. Providers appealing on their own behalf must submit an external appeal within 60 days of the final adverse determination.
Health plans may charge a $25.00 fee to patients or their designees, not to exceed $75.00 in a single plan year. The fee is waived for patients who are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. Health plans may charge providers a $50.00 fee per appeal. This fee will be returned if the external appeal agent overturns the denial.
Expedited (Fast-Tracked) External Appeals
For an external appeal to be expedited, the denial must concern an admission, availability of care, continued stay, or health care service for which the patient received emergency services and remains hospitalized; or the patient's physician must attest that the patient has not received the treatment and a 30-day timeframe would seriously jeopardize the patient's life, health, or ability to regain maximum function, or a delay will pose an imminent or serious threat to the patient's health. Or the patient is suffering from a health condition that may seriously jeopardize his or her life, health, or ability to regain maximum function, or is undergoing a current course of treatment using a non-formulary drug. A patient may request an expedited internal and external appeal at the same time. A decision on an expedited external appeal will be made within 72 hours (or 24 hours for a non-formulary drug), even if all of the patient's medical information has not yet been submitted.
Submit an External Appeal
Complete the New York State External Appeal Application online.
To get started visit the secure DFS Portal:
If eligible, DFS will have the appeal reviewed by an independent external appeal agent that will either overturn (in whole or part) or uphold the denial.
Forms Needed Depending on Appeal Type
Use the links below to download the necessary form(s) for your appeal. If you send these after the appeal has been submitted, please include the DFS Case number on the form(s). Eligibility screening of the external appeal cannot be completed without all required documents.
1. Patient Consent to the Release of Records
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This form will be used to obtain privacy protected medical records. An actual signature is required. This form must be signed by the patient or their authorized representative. If the patient is a minor, the document must be signed by the parent or legal guardian. If the patient is deceased, the document must be signed by the patients’ healthcare proxy or executor. If signed by a guardian, healthcare proxy or executor, a copy of the legal supporting document should be included.
2. Physician Attestation Form – One of the physician attestation forms below may be required depending on your appeal type. An actual signature is required, so please download a printable copy to be signed. To appeal an experimental/investigational, clinical trial, out-of-network service or out-of-network referral denial, the physician must be licensed and board-certified or board-eligible and qualified to practice in the area of practice appropriate to treat the patient. For a rare disease appeal, a physician must meet the above requirements, but may be different that the patient’s treating physician.
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For all appeal types
This form is only needed for expedited Medical Necessity appeals. No Physician Attestation is required for standard Medical Necessity appeals.
Standard health services or procedures have been ineffective or would be medically inappropriate, or there does not exist a more beneficial standard health service or procedure covered by the health plan.
There exists a clinical trial which is open, for which the patient is eligible and has been or will likely be accepted.
The attesting physician may be different than the patient’s treating physician. The patient has a rare condition or disease for which there is no standard treatment that is likely to be more clinically beneficial to the patient than the requested service. The requested service is likely to benefit the patient in the treatment of the patient’s rare disease, and such benefit outweighs the risk of the service.
The health plan does not have an in-network provider with the appropriate training and experience to meet the health care needs of the patient.
The health plan offers an alternate in-network service that is not materially different from the out-of-network service.
The patient’s physician or prescriber must complete this attestation for any expedited formulary exception appeal. No Physician Attestation is required for standard Formulary Exception appeals
The External Appeal Agent
You will be notified when your appeal is assigned to an external appeal agent, who will request supporting documents. Respond immediately to that request. Once the agent makes a decision, additional information will not be considered. The agent will make a decision within 72 hours for expedited appeals (or 24 hours for a non-formulary drug), or 30 days for standard appeals (or 72 hours for a non-formulary drug). The external appeal agent's decision is binding on the patient and the patient's health plan.
Patients covered under Medicare are not eligible for an external appeal and should call (800) MEDICARE or visit www.medicare.gov. Patients covered under regular Medicaid are not eligible for an external appeal; however, patients covered under a Medicaid Managed Care Plan are eligible. All Medicaid patients may also request a fair hearing, and the fair hearing decision will be the one that applies. Call (800) 342-3334 or visit www.otda.state.ny.us/oah for fair hearing information.
For questions or help with an application call (800) 400-8882 or email [email protected]. If you are faxing an expedited appeal call (888) 990-3991.
External Appeal Form in Hard Copy
Online submissions are preferred, but if you choose you may instead complete the fillable PDF form below, and send it by email to [email protected], by fax to (800) 332-2729 or by certified/registered mail to Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210.
- New York State External Appeal Application (Fillable PDF)
External Appeal Forms in Other Languages
- Spanish: Solicitud de Apelación Externa del Estado de Nueva York (PDF). Llámenos al (800) 342-3736 si necesita ayuda gratis en su idioma.
- Bengali: নিউ ইয়র্ক স্টেটের বহিঃস্থ আপীলের আবেদন
- Chinese: 紐約州外部申訴申請表 (PDF). 請給我們打電話號碼 (800) 342-3736, 要求免費的語言協助服務。
- Creole: Aplikasyon Apèl Ekstèn eta New York (PDF). Tanpri rele nou nan (800) 342-3736 pou jwenn sèvis èd gratis nan lang.
- Italian: Richiesta di Ricorso Esterno dello Stato di New York (PDF). Chiamare il (800) 342-3736 per assistenza linguistica gratuita.
- Russian: ЗАЯВЛЕНИЕ ДЛЯ ПОДАЧИ ВНЕШНЕЙ АПЕЛЛЯЦИИ В ШТАТЕ НЬЮ-ЙОРК (PDF). Чтобы получить бесплатные переводческие услуги, позвоните, пожалуйста, по следующему номеру (800) 342-3736
- Korean: 뉴욕 주 외부 이의 제기 신청서 (PDF). 전화 (800) 342-3736 로 무료 언어 지원 서비스를 요청하십시오