Title: Section 98-2.7 - Screening of requests for external appeal

98-2.7 Screening of requests for external appeal.

(a) Requests for external appeals shall be submitted to the superintendent. Upon receipt of such requests completed in the form and manner prescribed by the commissioner and superintendent, the requests shall be screened by the superintendent to determine eligibility for external appeal pursuant to the criteria detailed in section 4910(2) of the Public Health Law and section 4910(b) of the Insurance Law and the following:
(1) The enrollee submitting the request or on whose behalf a request for external appeal was submitted, or in the case of a retrospective adverse determination, on whose behalf a health care service is delivered, is not covered exclusively by Title XVIII of the federal Social Security Act; and
(2) If the enrollee submitting the request or on whose behalf a request for external appeal was submitted, or in the case of a retrospective adverse determination, on whose behalf a health care service is delivered, is receiving benefits under both Title XVIII and Title XIX of the federal Social Security Act, the health care service being requested is a covered benefit under Title XIX.
(3) The request is substantially complete as appropriate for the type of determination to be appealed and contains the following:
(i) a copy of the final adverse determination letter from the health care plan notifying the enrollee that their request for health care services was denied on appeal; or
(ii) a copy of a letter from the health care plan to the enrollee indicating a joint agreement to waive any internal appeal offered by the health care plan; or
(iii) in the case of a retrospective adverse determination, a copy of the final adverse determination letter from the health care plan;
(iv) payment of a fee, if applicable, or a statement that a waiver of the fee has been requested;
(v) the signature of the enrollee, or a person authorized pursuant to law to consent to health care for the enrollee, authorizing release of medical and treatment information; and
(vi) in the case of a retrospective adverse determination, if the enrollee’s health care provider is requesting an external appeal and the enrollee’s acknowledgment of the external appeal request and consent for release of the enrollee’s medical records to a certified external appeal agent is obtained at the time health care services are provided, a copy of a letter sent by the enrollee’s health care provider to the enrollee notifying the enrollee that an external appeal of a retrospective adverse determination has been requested and that the enrollee’s medical records will be released to a certified external appeal agent.
(4) As applicable, the enrollee’s attending physician attestation is fully and appropriately completed by the attending physician in the form and manner prescribed by the commissioner and superintendent, or the enrollee has indicated that the attending physician attestation has been transmitted to the enrollee’s attending physician. An application shall not be considered incomplete or untimely solely on the basis of failure by the attending physician to submit such documentation within the enrollee’s 45 day timeframe for initiation of an external appeal request pursuant to section 4914(2)(a) of the Public Health Law, provided however, the application will not be forwarded to an external appeal agent until the attestation is submitted.
(5) If the attending physician is recommending that the enrollee participate in a clinical trial, the attending physician attests that:
(i) the enrollee has a life-threatening or disabling condition or disease, as defined in subdivision 7-a of section 4900 of the Public Health Law;
(ii) the enrollee meets the eligibility criteria for the clinical trial;
(iii) the clinical trial is open to the enrollee; and
(iv) the enrollee has been or will likely be accepted into the clinical trial.
(6) The external appeal request was submitted, in the form and manner prescribed by the commissioner and superintendent, to the superintendent within 45 days from the date the enrollee or, for provider initiated retrospective appeals, the enrollee’s health care provider, received notice that the health care plan made a final adverse determination or within 45 days from when the enrollee received a letter from the health care plan affirming that both the enrollee and the enrollee’s health care plan jointly agreed to waive the internal appeal process. Unless otherwise demonstrated, it shall be presumed that the enrollee, or the enrollee’s health care provider for provider initiated retrospective appeals, received the notice of final adverse determination or letter agreeing to waive the internal appeal process within eight days of the date on the notice of final adverse determination or the date on the letter agreeing to waive the internal appeal process.

(b) Screening of expedited appeals shall be initiated by the superintendent within 24 hours of receipt of the request. Screening of standard appeals shall be initiated by the superintendent within five business days of receipt of the request.

(c) In the event that additional information is required to process a request, the superintendent shall contact the initiator of the request, the enrollee’s health care plan or the enrollee’s attending physician, as appropriate, by the most efficient means available, to request the necessary information.

(d) A copy of appropriately completed requests for appeals of final adverse utilization review determinations made by entities certified under Article 44 of the Public Health Law that are determined to be eligible for external appeal shall be transmitted to the commissioner immediately after assignment to a certified external appeal agent.

(e) The superintendent shall notify the enrollee and the enrollee’s health care plan if a request is determined to be eligible for external appeal within seven days of receipt of a complete request for a standard appeal and within 48 hours of receipt of a complete request for an expedited appeal. Such notification shall include:
(1) identification of the certified external appeal agent assigned to the appeal;
(2) notification to the enrollee of any unavoidable material affiliations concerning the certified external appeal agent assigned to the appeal, including a brief explanation of the nature of the material affiliation(s) pursuant to paragraph (1) of subdivision (e) of section 98-2.6 of this Subpart;
(3) for purposes of notifying the enrollee’s health care plan, a copy of the enrollee’s signed release of medical and treatment information, completed in a manner as prescribed jointly by the commissioner and superintendent and in accordance with section 2782 of the Public Health Law for confidential HIV related information and sections 33.13 and 33.16 of the Mental Hygiene Law for mental health related information; and
(4) for purposes of notifying the enrollee’s health care plan, as applicable, a copy of the attending physician’s attestation.

(f) If a fee is submitted and the health care plan’s determination is upheld by the external appeal agent, the superintendent shall forward the fee to the health care plan within seven days of receipt of the external appeal agent’s determination.

(g) If a fee is submitted and the health care plan’s determination is overturned in whole or in part by the external appeal agent, the superintendent shall return the fee to the enrollee or, in the case of a provider initiated retrospective appeal, the enrollee’s health care provider, within seven days of receipt of the external appeal agent’s determination.

(h) Those requests determined to be ineligible for external appeal shall be returned to the enrollee or, in the case of a provider initiated retrospective appeal, the enrollee’s health care provider, by the superintendent, with notification to the enrollee’s health care plan and attending physician, as appropriate, accompanied by an explanation as to why the request was determined to be ineligible for external appeal within seven days of receipt of a complete request for a standard appeal and within 48 hours of receipt of a complete request for an expedited appeal.