§ 4914. Procedures for external appeals of adverse determinations. (a)\nThe superintendent shall establish procedures by regulation to randomly\nassign an external appeal agent to conduct an external appeal, provided\nthat the superintendent may establish a maximum fee which may be charged\nfor any such external appeal, or the superintendent may exclude from\nsuch random assignment any external appeal agent which charges a fee\nwhich he deems to be unreasonable.\n (b) (1) The insured shall have four months to initiate an external\nappeal after the insured receives notice from the health care plan, or\nsuch plan's utilization review agent if applicable, of a final adverse\ndetermination or denial, or after both the plan and the insured have\njointly agreed to waive any internal appeal, or after the insured is\ndeemed to have exhausted or is not required to complete any internal\nappeal pursuant to section 2719 of the Public Health Service Act, 42\nU.S.C. § 300gg-19. Where applicable, the insured's health care provider\nshall have sixty days to initiate an external appeal after the insured\nor the insured's health care provider, as applicable, receives notice\nfrom the health care plan, or such plan's utilization review agent if\napplicable, of a final adverse determination or denial or after both the\nplan and the insured have jointly agreed to waive any internal appeal.\nSuch request shall be in writing in accordance with the instructions and\nin such form prescribed by subsection (e) of this section. The insured,\nand the insured's health care provider where applicable, shall have the\nopportunity to submit additional documentation with respect to such\nappeal to the external appeal agent within the applicable time period\nabove; provided however that when such documentation represents a\nmaterial change from the documentation upon which the utilization review\nagent based its adverse determination or upon which the health plan\nbased its denial, the health plan shall have three business days to\nconsider such documentation and amend or confirm such adverse\ndetermination.\n (2) The external appeal agent shall make a determination with regard\nto the appeal within thirty days of the receipt of the request therefor,\nsubmitted in accordance with the superintendent's instructions. The\nexternal appeal agent shall have the opportunity to request additional\ninformation from the insured, the insured's health care provider and the\ninsured's health care plan within such thirty-day period, in which case\nthe agent shall have up to five additional business days if necessary to\nmake such determination. The external appeal agent shall notify the\ninsured, the insured's health care provider where appropriate, and the\nhealth care plan, in writing, of the appeal determination within two\nbusiness days of the rendering of such determination.\n (3) Notwithstanding the provisions of paragraphs one and two of this\nsubsection, if the insured's attending physician states that a delay in\nproviding the health care service would pose an imminent or serious\nthreat to the health of the insured, or if the insured is entitled to an\nexpedited external appeal pursuant to section 2719 of the Public Health\nService Act, 42 U.S.C. § 300gg-19, the external appeal shall be\ncompleted within no more than seventy-two hours of the request therefor\nand the external appeal agent shall make every reasonable attempt to\nimmediately notify the insured, the insured's health care provider where\nappropriate, and the health plan of its determination by telephone or\nfacsimile, followed immediately by written notification of such\ndetermination.\n (4) (A) For external appeals requested pursuant to paragraph one of\nsubsection (b) of section four thousand nine hundred ten of this title,\nthe external appeal agent shall review the utilization review agent's\nfinal adverse determination and, in accordance with the provisions of\nthis title, shall make a determi
‹ Prev All New York sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.