Patients have the right to an appeal when health care services are denied by health insurance as not medically necessary. If you are denied Hep C medication after a medical provider has recommended you for treatment, you have the right to appeal, request a fair hearing or file a complaint.
Patients and Providers can file an appeal
Internal appeals are submitted to the health insurance company directly. Call the health insurance company for instructions.
External appeals must be filed within 60 days of the final adverse determination. Health plans may charge providers a $50.00 fee per appeal. This fee will be returned if the external appeal agent overturns the denial.
How to File an External Appeal
- Complete the New York State External Appeal Application and send it by fax to (800) 332-2729 or by certified or registered mail to the Department of Financial Services (DFS), PO Box 7209, Albany NY, 12224.
- If eligible, DFS will have the appeal reviewed by an independent external appeal agent that will either overturn (in whole or part) or uphold the denial. You will be notified when your appeal is assigned to an external appeal agent, who will request supporting documents. You should respond immediately to that request.
- Once the agent makes a decision, additional information will not be considered. The agent will make a decision within 72 hours for expedited appeals or 30 days for standard appeals. The external appeal agent’s decision is binding on the patient and the patient’s health plan.
- Patients covered under Medicare are not eligible for an external appeal and should call (800) MEDICARE or visit medicare.gov.
- Patients covered under fee for service Medicaid are not eligible for an external appeal.
- Patients covered under a Medicaid Managed Care Plan are eligible.
For questions or help with an application visit www.dfs.ny.gov/ExternalAppeal, call (800) 400-8882 or email firstname.lastname@example.org. If you are faxing an expedited appeal call (888) 990-3991.
All Medicaid patients may also request a fair hearing. Call (800) 342-3334 or visit otda.state.ny.us/oah for fair hearing information.
How to File a Complaint
Only patients have the right to file a complaint.
Department of Financial Services reviews complaints to gather information on compliance with law and to detect patterns of wrongdoing and/or fraud. They cannot attempt to resolve or otherwise handle every individual complaint. They will notify you if your complaint is not being individually reviewed.
Use the online consumer complaint to file a complaint about a health insurance company. Be aware that they may share a copy of your complaint with the company or individual you are complaining about.