NY Manual
SHP Manual

New York Provider Manual
15.17 Expedited Appeals – Commercial, CHPlus | 16.1 Payees

15.18 External Review – Commercial, CHPlus

External Appeal

In connection with a concurrent or retrospective review, members and a members' healthcare providers are able to request an external appeal for four (4) types of adverse determinations: 1) services deemed not medically necessary, 2) services deemed experimental or investigational (include clinical trials and treatments for rare diseases), 3) services denied because they are not materially different from services available in-network, 4) or in the instance of a denied referral to an out-of-network non-participating provider.

A member may elect to file an external appeal at the time of the initial adverse determination if s/he and Healthfirst both agree to waive Healthfirst's internal appeals process. If both the member and Healthfirst agree to waive the Healthfirst appeals process, then the member must ask for the external appeal within four (4) months of the date of the denial determination. Providers may elect an external appeal on behalf of the member within sixty (60) days of the final adverse determination.

Members are also instructed about the external appeal process at the time of the internal appeal determination if any part of the denial determination is upheld. Healthfirst provides a copy of the External Appeal Process developed jointly by the State Department of Health (SDOH) and the State Department of Financial Services (DFS) including an application and instructions to members or providers to request an external appeal.

Members must file their external appeal with the DFS within four (4) months of the time that Healthfirst gave the notice of final adverse determination from the appeals process.

For Providers

Healthfirst will forward an external appeal application for providers to appeal a concurrent or retrospective final adverse determination within three (3) calendar days of the provider’s request.

The external appeal determination decision will be made in thirty (30) days; however, more time may be needed if the external appeal reviewer needs to obtain more information (up to five [5] additional days).

The member and Healthfirst will be notified of the final determination within two (2) days after the external appeal decision is made. The external appeal agent may also notify providers of the outcome of the member’s external appeal, where appropriate.

Providers must not seek reimbursement (except for copayments, coinsurance, or deductibles, where applicable) from members when a provider-initiated external review of a concurrent adverse determination determines that the healthcare services are not medically necessary.

The member’s healthcare provider can request an expedited appeal if the delay could cause the member serious harm. These expedited external appeal determinations will be made within three (3) days, and notification by phone or fax to the member and Healthfirst will occur. The external appeal agent may also notify providers of the outcome of the member’s external appeal, where appropriate.

In most cases, Healthfirst will retain financial responsibility for external appeals that have been assigned to a certified external appeal agent. Providers are responsible for the costs of an unsuccessful appeal of a concurrent adverse determination. Providers and Healthfirst will share the cost of the external review when a concurrent adverse determination is upheld in part. If Healthfirst reverses a denial which is the subject of an external appeal after assignment to a certified external appeal agent but prior to assignment of a clinical peer reviewer, Healthfirst shall be responsible for the administrative fee as assessed.