New York provides policy-holders and plan participants with the right to request external review of any medical claim denied because the proposed care or service is “not medically necessary” or “experimental” or “investigational.”  Generally, such a request must be filed with the New York State Insurance Department within 45 days after the date of a final denial (although its allowance for mailing time may extend this deadline by several days).  A request should be submitted to the Department on the form which it supplies for that purpose, and should be accompanied by the required fee (at present, $50).  A standard appeal will be decided within 30 days, unless additional information is required.  An expedited appeal (applicable when a physician has stated that a delay would pose an imminent or serious threat to the patient’s health) will be decided in 3 days.

The external review procedure is not mandatory and was intended to benefit consumers by providing a mechanism, short of litigation, for obtaining review by a qualified “neutral” health care professional (that is, one with no connection to either your medical plan or your health care provider) in accordance with more uniform, patient-friendly definitions of “medical necessity” and of “experimental/investigational.”  In practice, the external review procedure appears to be serving its purpose, and should be considered a valuable option to individuals seeking review of these types of claims.

Generally, all insured health care coverage (whether provided to you as an individual or as part of a group employer-sponsored plan) will be subject to New York's external review requirements.  However, because "self-funded" (sometimes also referred to as "self-insured") employer-sponsored plans are exempt from state insurance regulation, such plans may not be required to provide an external review right (though some self-funded plans may choose to do so voluntarily).  See, "What does it Mean if My Plan is "Self-Insured" or "Self-Funded"?