External Review for Health Claim Denials
New York’s External Review Procedure May Be Useful for Health Insurance Claim Denials Based On Lack of Medical Necessity or the Experimental or Investigational Nature of the Treatment
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 many claim denials are overturned through the external appeal process. Consequently, external review should be considered a valuable option to individuals seeking review of these types of health insurance claim denials.
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).
In November, 2011, Mr. Scherzer was interviewed by ABC News with regard to New York’s External Review Program. A young woman requested external review of her insurance company’s denial of coverage for her life-saving treatment. After reviewing documentation submitted by the young woman and her physicians, Mr. Scherzer (who was not involved in the claim) determined that the claim had been improperly classified, and that had the external review program properly recognized that the young woman suffered from a rare disease, her claim for coverage would most likely have been approved. This underscores that consulting with a lawyer in relation to the appeal of a denied claim can help to reverse an improper claim denial. A transcript of the ABC News Story appears here: Attorney Mark Scherzer Discussing Health Insurance Claim on ABC News.
New York ERISA and Private Insurance Lawyers (including New York County, Bronx County, Kings County, Richmond County, Queens County, Nassau County, Suffolk County, Rockland County, Westchester County, Putnam County, Orange County, Sullivan County, Ulster County, Dutchess County, Delaware County, Greene County, Columbia County, Albany County, Rennselaer County, Clinton County, Jefferson County, Oneida County, Schenectady County, Otswego County, Saratoga County and St. Lawrence County)