New York

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • 1. Appeal the decision;
  • 2. Request an independent medical review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited internal appeal, if applicable. You can request an expedited internal appeal if your insurer denied you continued or extended health care services, procedures, or treatments for which you are undergoing or home health services following your discharge from an inpatient hospital admission.[2] You can also request an expedited internal appeal if your health care provider believes that your case requires an immediate appeal. You should have received instructions for requesting an expedited appeal with your determination letter.[3] If you did not, contact your insurer and request instructions.
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.
  • Complete second level of internal appeal (optional). Your health insurer may offer a second level of internal appeal which is voluntary. You are not required to participate in the second level under New York law.[4] Your health insurer should notify you of the option of filing a second level internal appeal, and what you need to do to request a second level appeal, including any additional documentation you should submit.[5]

The internal appeal process, including both first level and second level appeals, should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days, including both first level and second level appeals, if you have received the service or treatment but are waiting for reimbursement.[6] An expedited internal appeal should take no longer than 72 hours to receive a decision.[7]

During an external review, an independent third party reviews your insurer’s decision.[8] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New York law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal.

You can also request an expedited external review if one of the following circumstances applies:

  • The denial concerns an admission, availability of care, continued stay, or health care service for which you received emergency services and have not yet been discharged from the hospital;
  • Waiting 30 days for the requested treatment would seriously jeopardize your life, health, or ability to regain function; or
  • If a delay in treatment would pose an imminent threat to your health.[9]

You should submit your request for external review to the New York Department of Financial Services (“Department”).[10] You must submit your request within four months from the date of the determination letter from the first level of appeal even if your health insurer offers a second level of internal appeal.[11]

Information. You can find a copy of the external review request form here. You should include the following information with your request:

  • The name of the applicant;
  • The name, address, telephone number, and email address of the patient;
  • The name of the insurance company;
  • The name, address, and telephone number of the patient’s healthcare provider;
  • Reason for health plan denial; and
  • Description of complaint and dates of service.[12]

Supporting documents. You should submit any new information and documentation not included with your request for an internal appeal with your request for an external review. If you are requesting an expedited review, you should also attach a Physician Attestation form, which is including in the external review request packet.[13]

Filing fee. You must pay a $25 filing fee by check or money order made payable to your health insurer, if your health insurer requires such a fee.[14] The fee can be waived if you are covered by Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. If you qualify for the wavier or your appeal is successful, your fee will be refunded to you.[15]

Submitting a standard external request. You can submit the request to the Department by fax to (800) 332-2729 or by certified or registered mail to the following address:

Department of Financial Services
P.O. Box 7209
Albany, NY 12224[16]

Submitting an expedited review. If you are requesting an expedited external review, you must contact the Department of Financial Services at (888) 990-3991.[17]

The external review process should take no more than 30 days from the date the external appeal agent receives your request. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received.[18]

If you are a New York resident and you believe your insurer did something illegal or unethical, you can file a complaint with the Department.

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The name and address of insurance company;
  • The type of insurance, type of claim, policy number, claim number, and date of loss or service;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[19]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[20]

How to submit. The complaint may be submitted online, faxed to (212) 480-6282, or mailed to the following address:

Department of Financial Services
Consumer Assistance Unit
One Commerce Plaza
Albany, NY 12257 [21]

The Department will review your complaint to determine if the Department can assist you. You will be notified if the Department has decided not to review your case. Otherwise, the Department will attempt to resolve your complaint with your health insurer.[22] It will investigate to determine if your insurer is breaking with state law or committing fraud.[23] The Department can force the insurer to comply with your insurance policy, issue citations, or fine the insurer. This process can take anywhere from a few weeks to a few months.

You can contact the New York Department of Financial Services at (212) 480-6400 or (800) 342-3736. The Department is open from 8:30 a.m. to 4:30 p.m. Monday through Friday.