• Appeals Procedure Form
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• Change Form
• HIPPA Release Form
• Indecs Claim Form
• You, your authorized designee, and, in a retrospective review case, your health care
  provider may request a Level One internal appeal of an adverse determination, verbally
  or in writing, within 60 business days from the date that you receive notice of the adverse
  determination. To request a Level One Internal Appeal verbally, you may call 1-800-764-
  3433. To submit a written request for a Level One Internal Appeal, you may write to
  HealthCare Strategies, Inc., 9841 Broken Land Parkway, Suite 315, Columbia, Maryland
  21046.
• Your case will differ, depending upon the urgency of the case. In most cases, a standard
  Level One Internal Appeal, described below, will be appropriate. In “urgent
  cases,” an expedited Level One Internal Appeal is available; the expedited Level
  One Internal Appeal process is described after standard Level One Internal
  Appeal below.

2. Standard Level One Internal Appeal.

• We will acknowledge your Level One Internal Appeal in writing, within five (5) business
  days after receiving it.
• When one or more Level One Internal Appeals are received (for example, you submit an
  appeal, then your health care provider submits an appeal on your behalf), a single Level
  One internal Appeal will be conducted by a clinical peer reviewer (a physician who
  possesses a current and valid non-restricted license to practice medicine, or a heath care
  professional other than a licensed physician who, were applicable, possesses a current
  and valid non-restricted license, certification, or registration or, where no provision for a
  license, certificate, or registration exists, is credentialed by the national accrediting body
  appropriate to the profession and is in the same profession/specialty as the health care
  provider who typically manages the medical condition), who did not make the initial
  adverse determination.
• The clinical peer reviewer will render a determination within 30 calendar days after
  receipt of all necessary information. Written notice of the determination will be provided
  to you and any other qualified party who submitted a Level One Internal Appeal within
  two (2) business days after the determination is made, but in no event later than 30
  calendar days after receiving all necessary information. Failure to render a determination
  within the time periods required by Article 49 of the New York Insurance Law will be
  deemed to be a reversal of the initial adverse determination.
• The notice will include detailed reasons and the clinical rational for the determination. If
  the determination is adverse, the notice will describe the procedure for filing an external
  appeal of the adverse determination. The external appeal process is described in
  paragraph “o” below. Note – If you submit a Level Two Internal Appeal, the review
  appeal may take longer than the 45-day time frame for requesting an external appeal
  through New York State, which begins on the date you receive the final adverse
  determination notice upon completion of Level One Internal Appeal.

Expedited Level One Appeal.

• For cases involving a prospective or concurrent (but not retrospective) review decision
  (such as the review of continued or extended health care services; additional services
  rendered in the course of continued treatment; or any other issue with respect to which a
  provider requests an immediate review), you, your authorized designee, or a provider
  may request an expedited Level One Internal Appeal of the initial adverse determination.
• When a request for expedited Level One Internal Appeal is received, the appeal will be
  conducted by a clinical peer reviewer who did not render the initial adverse
  determination. The Plan’s Managed Benefits Program Coordinator will provide
  reasonable access to the clinical peer reviewer assigned to the appeal, within one (1)
  business day following receipt of notice of the request for appeal, to ensure that all
  relevant information is available to the clinical peer reviewer. You may ask that your
  provider and the clinical peer reviewer exchange information by telephone or fax.
• Within 48 hours of review by us of all information needed for the appeal, the clinical peer
  reviewer will decide the expedited Level One Internal Appeal. Failure to render a
  determination within the time periods required by Article 49 of the New York Insurance
  Law will be deemed to be a reversal of the initial adverse determination.
• Notice will be provided to you and the provider, by telephone and in writing, within 24
  hours of the determination. The notice will include all of the information described and
  enclosed in a notice of standard Level One Internal Appeal determination (see above).
  Note – If you request a Level Two Internal Appeal, the appeal may take longer than the
  45-day time frame for requesting an external appeal through New York State, which
  begins on the date you receive the final adverse determination notice upon completion of
  Level One Internal Appeal.

Level Two Internal Appeals.

• After you receive notice of a Level One internal appeal determination, if you are still not
  satisfied, you or your authorized designee may submit a Level Two Appeal, verbally or in
  writing. (You also have an option to apply for an external appeal, see paragraph e.
  below). The Level Two internal appeal must be received by us within 60 business days
  from the date of the Level One Internal Appeal determination.
• We will acknowledge your Level Two Internal Appeal, in writing, within 15 calendar days
  after receiving it. The acknowledgement will identify additional information, if any,
  needed for the Level Two Internal Appeal.
• Your case will be reviewed by at least one clinical peer reviewer who did not make the
  prior determinations.
• In “urgent cases” where a delay would significantly increase the risk to your health, we
  will make a Level Two Internal Appeal determination and call you within the lesser of two
  (2) business days or 72 hours after receiving all information needed for the review.
  Written notice of the Level Two Internal Appeal determination will also be provided within
  two (2) business days.
  In all other cases, we will make a Level Two Internal Appeal determination within 30
  business days after receiving all information needed for the review. Written notice of the
  determination will be provided to you within two (2) business days after the determination
  is made, but no later than 30 business days after receiving all necessary information.
• The notice you receive will include detailed reasons for the Level Two Internal Appeal
  determination and, if a clinical matter is involved, the clinical rationale for the
  determination. The notice will also advise you of the right to apply for an external appeal,
  if the time frame for applying has not expired by the date of receipt of notice of an
  adverse determination on Level Two Internal Appeal.

WHAT ARE “EXTERNAL” MANAGED CARE APPEALS?

New York State Law gives you the right to an external appeal when health care services are denied by
one of the Plan’s utilization Review Agencies, on the basis that the services are not Medically Necessary
or that the services are Experimental or Investigational.
To request an external appeal you must complete a New York State External Appeal application form and
send it to the New York State Insurance Department within 45 days of when you received a notice of final
adverse determination from first level internal appeal process OR within 45 days of receiving written
confirmation from the plan that the internal appeal has been waived. If all applicable items required by
the State are not completed, your request will not be accepted.

What is an External Appeal?

• An external appeal is a request that you make to the State of New York for an
  independent review of a denial of services by your health plan.
• Reviews are conducted by external appeal agents that are certified by the state and have
  a network of medical experts to review your health plan’s denial of services.
• You must complete the New York External Appeal Application which can be obtained
  from your Local School District Heath Plan Representative, any of the Plan’s Managed
  Care vendors’ utilization review firms or the Health Plan’s claims administrator. Upon
  completion, submit the application to the New York State Insurance Department to
  request an external appeal.

Eligibility for an External Appeal.

To be eligible for an external appeal:

• You must have received a final adverse determination as a result of your health plan’s
  internal utilization review appeal process OR you and your health plan must have agreed
  to waive that appeal process. A final adverse determination is written notification from
  your health plan that your health care service has been denied through the Plan’s internal
  appeal process. Because you are entitled to an internal appeal process through the
  Plan’s utilization review agents, and then through the Health Plan’s appeal committee,
  the External Appeal Application may be made at the same time you file your second level
  appeal to the Health Plan Committee through your Local School District Health Plan
  Representative.
• If both you and your health plan agree to waive the internal appeal process, the health
  plan will confirm the agreement in writing.
• You must submit a request for an external appeal to the State within 45 days from when
  you received a notice of final adverse determination from your health plan OR within 45
  days of receiving written confirmation from your health plan that the internal appeal
  process has been waived.
• If you do not file a request for an external appeal with the State within this 45-day period,
  you will not be eligible for an external appeal. As indicated in the section “How do I
  appeal a Managed Decision I disagree with?” you are entitled to an Internal Appeal by
  the Managed Care Vendor. If that Appeal results in a continued adverse decision, you
  must file a request for external appeal within 45 days of your receipt of the notice of final
  adverse determination from the plan’s first level appeal process (through the Managed
  Care Coordinator) to be eligible for an external appeal.
• If services are denied as Experimental or Investigational, you must have a life-threatening
  or disabling condition to be eligible for an external appeal and your attending physician
  must complete the Attending Physician Attestation form and send the form to the State
  Insurance Department. This form is also available from your Local School District, the
  Plan’s Managed Care vendors or the Plan’s claims administrator.
• If the Covered Person’s attending physician has certified that the patient has a lifethreatening
  or disabling condition or disease for which (a) standard health services or
  procedures have been ineffective or would be medically inappropriate, or (b) there does
  not exist a more beneficial standard health services or procedure covered by the health
  care plan, or (c) there exists a clinical trial, and if the covered patient’s attending
  physician, who must be a licensed, board-certified or board-eligible physician qualified to
  practice in the area of practice appropriate to treat the insured’s life-threatening or
  disabling condition or disease, has recommended either (1) a health service or procedure
  (including a pharmaceutical product) that, based on two documents from the available
  medical and scientific evidence, is likely to be more beneficial to the insured than any
  covered standard health service or procedure; or (2) a clinical trial for which the insured is
  eligible. Any physician certification must include a statement of the evidence relied upon
  by the physician in certifying his or her recommendation, and the specific health service
  or procedure recommended by the attending physician must otherwise be covered under
  the Plan except for the Plan’s determination that the health service or procedure is
  Experimental or Investigational.

You may only appeal a service or procedure that is a covered benefit under your contract. The external appeal process may not be used to expand the coverage of your Health Plan. The appeal cannot be for workers’ compensation claims or for claims under no-fault auto coverage.

2. What About the Second Level of Internal Appeal to my Health Plan Appeal Committee?

• You are not required to seek a second level of internal appeal with your health plan in
  order to request an external appeal, although you may file one simultaneously.
• If you seek a second level of internal appeal with your health plan, you may not have time
  to request an external appeal. You must request an external appeal within 45 days of
  receiving the determination from the health plan’s first level of internal appeal.

3. Am I Eligible for an External Appeal if I am Covered by Medicare or Medicaid?

• You are not eligible for this external appeal process when Medicare is your only (or
  primary) source of health services. If you have coverage under Medicare, you must file a
  complaint with the federal government for denials of service.
• If you have coverage under Medicare and Medicaid, this external appeal process may
  only be used to appeal denials of services or treatment covered by Medicaid.
• If you have Medicaid coverage, you may also request a fair hearing. If you have
  requested an external appeal and a fair hearing, the determination in the fair hearing
  process will be the one that applies. If you have questions about the fair hearing
  process, you should contract the New York State Department of Health at 1-800-206-
  8125.

4. Eligibility for an Expedited (Fast-Tracked) External Appeal.

• • If your attending physician attests that a delay in providing the treatment or service poses
    an imminent or serious threat to your health, you may request an expedited appeal.
    When requesting an expedited appeal, make sure you give the Attending Physician
    Attestation to your doctor to complete. Your appeal will not be forwarded to the external
    appeal agent until your physician sends this attestation to the Insurance Department.

5. How Long an External Appeal Will Take?

• Expedited Appeals:
  The external appeal agent must make a determination within three (3) days of receiving
  your request for an external review from the state.
• Standard Appeals:
  When your appeal is not expedited, the external appeal agent must make a determination
  within 30 days of receiving your request for an external review from the state. If
  additional information is requested, the external appeal agent has five (5) additional
  business days to make a determination.

6. The Cost to You for an External Appeal.

The Health Plan charges a fee of $50.00 for an external appeal.

• If you have coverage under Medicaid Child Health Plus, or your health plan determines
  that the fee will pose a hardship, you will not be required to pay a fee.
• You must submit the fee with your application for an external appeal. If you fax your
  application to the Insurance Department, you must send the fee within three (3) business
  days to the Insurance Department. If the fee is not sent to the Insurance Department
  within this time frame, the external appeal agent will suspend review of your appeal until
  payment is received.
• Only checks or money orders, made payable to your health plan, will be accepted.
• If the external appeal agent overturns your health plan’s determination, the fee will be
  refunded to you.

7. When Information May be Submitted to the External Appeal Agent.

• If your case is determined to be eligible for external review, you and the Health Plan will
  be notified of the certified external appeal agent assigned to review your case.
• The Health Plan must send any medical and treatment record either it, or its UR vendors,
  have to the external appeal agent.
• When the external appeal agent reviews your case, the agent may request additional
  information from you or your doctor. This information should be sent immediately to the
  external appeal agent.
• You and your doctor can submit information even when the external appeal agent has not
  requested specific information. You must submit this information within 45 days from
  when your health plan made a final adverse determination or from when you and your
  health plan agreed to waive the internal appeal process.
  *** It is important to send this information immediately. Once the external appeal agent
  makes a determination or once your 45-day time period ends, you will be unable to
  submit additional information.

8. What Happens When an External Appeal Agent Makes a Decision?

• Expedited Appeals:
  If your appeal was expedited, you and your health plan will be notified immediately by
  telephone or fax of the external appeal agent’s decision. Written notification will follow.
• Standard Appeals:
  If your appeal was not expedited, you and your health plan will be notified in writing within
  two (2) business days of the external appeal agent’s decision.
• Binding Decision:
  The decision of the external appeal agent is binding on you and your health plan.
  If you have any questions, please contact your Local School District Health Plan
  Administrator, the Health Plan’s claims administrator or any of the Plan’s Managed Care
  vendors whose toll-free telephone numbers are listed on your ID cards and in Appendix A
  of this document. You may also contact the New York State Insurance Department at 1-
  800-400-8882 or visit their web site at www.ins.state.ny.us.