There is a question on whether the claim for out-of-network care you received was coded correctly by the provider and accurately reflects the treatment received, and the associated NSA protections related to cost sharing and surprise billing.Įxpedited (Fast-Tracked) External Appealsįor an external appeal to be expedited, the denial must concern an admission, availability of care, continued stay, or health care service for which the patient received emergency services and remains hospitalized or the patient's physician must attest that the patient has not received the treatment and a 30-day timeframe would seriously jeopardize the patient's life, health, or ability to regain maximum function, or a delay will pose an imminent or serious threat to the patient's health.Incorrect cost-sharing was applied to your bill for either emergency services or a surprise bill or.The health plan determines that the out-of-network services received do not qualify as a surprise bill or.The health plan determines that out-of-network emergency services received were non-emergent or.You may file an external appeal if your health plan issued a final adverse determination for any of the following reasons: This fee will be returned if the external appeal agent overturns the denial. Health plans may charge providers a $50.00 fee per appeal. The fee is waived for patients who are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship. Health plans may charge a $25.00 fee to patients or their designees, not to exceed $75.00 in a single plan year. Providers appealing on their own behalf must submit an external appeal within 60 days of the final adverse determination. If DFS does not receive your application within 4 months, you will not be eligible for an external appeal. If your health plan offers a second-level internal appeal, you do not have to file one, but if you do, you must still submit an external appeal to DFS within 4 months of the first appeal decision. DeadlinesĬonsumers must send an external appeal application to DFS within 4 months from the date of the final adverse determination from the first level of appeal with the health plan or the waiver of the internal appeal process. Data can be searched by year, diagnosis, treatment, or key words like cancer, apnea, etc. Search and review prior external appeal decisions using our External Appeals Database. Health care providers also have the right to an external appeal when health care services are denied (concurrently or retrospectively). This appeal is known as an external appeal. If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or out-of-network, you have the right to appeal to the Department of Financial Services (DFS).
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