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NEWYORKSTATEEXTERNALAPPEALAPPLICATION Completeandsendthisapplicationwithin4monthsoftheplansfinaladversedeterminationforhealthservicesifyou arethepatientorthepatientsdesignee,orwithin60daysifyouareaproviderappealingonyourownbehalftoDFS. Mailto:NewYorkStateDepartmentofFinancialServices,99WashingtonAvenue,Box177,Albany,NY12210 orFaxto:(800)3322729. Forhelp,call(800)4008882oremailexternalappealquestions@dfs.ny.gov. Gender:MaleFemaleNonSpecified (New York State)

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NEWYORKSTATEEXTERNALAPPEALAPPLICATION
Completeandsendthisapplicationwithin4monthsoftheplan’sfinaladversedeterminationforhealthservicesifyou
arethepatientorthepatient’sdesignee,orwithin60daysifyouareaproviderappealingonyourownbehalftoDFS.
Mailto:NewYorkStateDepartmentofFinancialServices,99WashingtonAvenue,Box177,Albany,NY12210
orFaxto:(800)332‐2729. Forhelp,call(800)400‐8882oremailexternalappealquestions@dfs.ny.gov.
1.ApplicantName:
2.PatientName:
DateofBirth:
Gender:MaleFemaleNon‐Specified
3.PatientAddress:
Street:
City: State: ZipCode:
4.PatientPhoneNumber: Primary:( ) Secondary:( )
5.PatientEmailAddress:
6.PatientHealthPlan:
ID#:
7.Patient’sPhysician/Prescriber:
8.Physician/PrescriberAddress:
Street:
City: State: ZipCode:
9.Physician/PrescriberPhone#:( ) Fax: ( )
10.IfthepatienthasaMedicaidManagedCarePlan,haspatientrequesteda
fairhearingthroughMedicaidorreceivedafairhearingdetermination?
Yes
No
Don’tknow
11.Tobecompletediftheapplicantisthepatient’sdesignee
Completethissectiononlyifadesigneeissubmittingthis appealon apatient’s behalf. Ifthepatient’sprovider is the
designeecompletesection14insteadofthissection.
NameofDesignee:
RelationshiptoPatient:
Address:
Street:
City: State: ZipCode:
PhoneNumber: ( ) Fax:( )
DesigneeEmailAddress:
12.ReasonforHealthPlanDenial‐checkonlyoneandattachacompletedphysician’sattestationforallexpedited
appealsandalldenialreasonsexceptforNotMedicallyNecessary:
Notmedicallynecessary Experimental/investigationalforaclinicaltrial
Experimental/investigational Experimental/investigationalforararedisease
Out‐of‐networkandthehealthplanproposed
analternatein‐networkservice
Out‐of‐networkreferral
FormularyException(forindividualandsmallgroupcoverage,otherthanMedicaidorChildHealthPlus)
1 EA 09/18
2 EA 09/18
13. This appeal may be expedited. Expedited decisions are made within the timeframes described below, even if the
patient, physician or prescriber does not provide needed medical information to the external appeal agent.
If Expedited
check one:
Expedited Appeal (72 hours). Denial concerns an admission, availability of care, continued stay, or
health care service for which the patient received emergency services and remains hospitalized.
Expedited Appeal (72 hours). 30-day timeframe will seriously jeopardize patient’s life, health, or
ability to regain maximum function, or a delay will pose an imminent or serious threat to patient’s
health, and patient’s physician will complete the Physician Attestation and send it to the Department
of Financial Services.
Expedited Formulary Exception (24 hours). The patient is suffering from a health condition that
may seriously jeopardize his or her life, health, or ability to regain maximum function, or is
undergoing a current course of treatment using a non-formulary drug, and patient’s prescribing
physician or other prescriber will complete the Physician Attestation and send it to the Department of
Financial Services.
If Standard
check one:
Standard Formulary Exception (72 hours)
Standard Appeal for all other appeals (30
days)
*** If expedited you must call 888-990-3991 when the application is faxed***
14. To be completed if applicant is patient’s provider
Health care providers have a right to an external appeal of a concurrent or retrospective final adverse determination.
This section should be completed by providers appealing on their own behalf or appealing as a patient’s designee. The
initial denial and final adverse determination from the first level of appeal must be attached.
Provider filing own behalf Provider filing as designee on behalf of patient
Provider Name:
Person or Firm Representing Provider
(if applicable):
Contact Person for Correspondence:
Address for Correspondence:
Street:
City: State: Zip Code:
Phone Number: ( ) Fax: ( )
Email Address:
I attest that the information provided in this application is true and accurate to the best of my knowledge. I agree not
to pursue reimbursement for the service from the patient if a concurrent denial is upheld by the external appeal
agent, except to collect a copayment, coinsurance or deductible. If I appeal a concurrent denial on my own behalf, and
not as the patient’s designee, I agree to pay the external appeal agent’s fee in full if the health plan’s concurrent
denial is upheld, or to pay half of the agent’s fee if the health plan’s concurrent denial is upheld in part. I agree not to
commence a legal proceeding against the external appeal agent to review the agent’s decision; provided, however,
this shall not limit my right to bring an action against the external appeal agent for damages for bad faith or gross
negligence, or to bring an action against the health plan.
Provider Signature:
3 EA 09/18
15. Description and date(s) of Service: (Attach any additional information you want considered):
16. External Appeal Eligibility (Check one):
Attached is final adverse determination from the health plan.
Attached is the health plan’s letter waiving an internal appeal.
Patient requests expedited internal appeal at same time as the external appeal.
Health plan did not comply with internal appeal requirements for patient appeal.
17. External Appeal Fee
You must enclose a check or money order made out to the health plan if required by the health plan. If the appeal is
decided in your favor, the fee will be returned to you.
Please check one:
Enclosed is a check or money order made out to the health plan.
Application was faxed and fee will be mailed to the Department within 3 days.
Patient is covered under Medicaid or Child Health Plus.
Patient requests fee waiver for hardship and will provide documentation to the health plan.
Health plan does not charge a fee for an external appeal or fee is not required.
4 EA 09/18
PATIENT CONSENT TO THE RELEASE OF RECORDS FOR NEW YORK STATE EXTERNAL APPEAL
The patient, the patient’s designee, and the patient’s provider have a right to an external appeal
of certain adverse determinations made by health plans.
When an external appeal is filed, a consent to the release of medical records, signed and dated by the patient, is
necessary. An external appeal agent assigned by the New York State Department of Financial Services will use this
consent to obtain medical information from the patient’s health plan and health care providers. The name and
address of the external appeal agent will be provided with the request for medical information.
I authorize my health plan and providers to release all relevant medical or treatment records related to the external
appeal, including any HIV-related information, mental health treatment information, or alcohol / substance use
treatment information, to the external appeal agent. I understand the external appeal agent will use this
information solely to make a decision on the appeal and the information will be kept confidential and not released
to anyone else. This release is valid for one year. I may revoke my consent at any time, except to the extent that
action has been taken in reliance on it, by contacting the New York State Department of Financial Services in
writing. I understand that my health plan cannot condition treatment, enrollment, eligibility, or payment on
whether I sign this form. I acknowledge that the decision of the external appeal agent is binding. I agree not to
commence a legal proceeding against the external appeal agent to review the agent’s decision; provided, however,
this shall not limit my right to bring an action against the external appeal agent for damages for bad faith or gross
negligence, or to bring an action against my health plan.
If the patient or the patient’s designee submits this application, by signing the Patient Consent to the Release of
Records for New York State External Appeal, the patient attests that the information provided in this application is
true and accurate to the best of his or her knowledge.
Signature of patient is required below. If the patient is a minor, the document must be signed by their parent or
legal guardian. If the patient is deceased, the document must be signed by the patient’s healthcare proxy or
executor. If signed by a guardian, power of attorney, healthcare proxy or executor, a copy of the legal supporting
document should be included.
Signature:
Print Name:
Relationship to patient, if
applicable:
Patient Name: Age:
Patient’s Health Plan ID#:
Date:
(required)
5 EA 09/18
PHYSICIAN ATTESTATION FOR AN EXTERNAL APPEAL
The patient’s physician must complete this attestation for any external appeal of a health plan’s denial of services as
experimental/investigational; a clinical trial; a rare disease; out-of-network; or for an expedited appeal. The patient’s
prescriber may also request an expedited formulary exception appe
al. The Department of Financial Services or the
external appeal agent may need to request additional information from you, including the patient’s medical records.
This information should be provided immediately.
Mail to: New York State Department of Financial Services, 99 Washington Avenue, Box 177, Albany NY, 12210
or Fax to: (800) 332-2729.
Type of Review
Requested:
Expedited Appeal (72 hours), or for a non-
formulary drug (24 hours)
If Expedited check
one:
Expedited Appeal (72 hours). Denial concerns an admission, availability of care, continued
stay, or health care service for which the patient received emergency services and remains
hospitalized.
Expedited Appeal (72 hours). 30-day timeframe will seriously jeopardize patient’s life,
health, or ability to regain maximum function, or a delay will pose an imminent or serious
threat to patient’s health.
Expedited Formulary Exception (24 hours). The patient is suffering from a health condition
that may seriously jeopardize his or her life, health, or ability to regain maximum function,
or is undergoing a current course of treatment using a non-formulary drug.
If Expedited
complete both:
I am aware that the external appeal agent may need to contact me during non-business
days for medical information, including medical records, and that a decision will be made by
the external appeal agent within 72 hours (or 24 hours for a non-formulary drug) of
receiving this expedited appeal request, regardless of whether or not I provide medical
information or medical records to the external appeal agent.
During non-business days, I can be reached at: ( )
• For an expedited appeal, the patient’s physician, or for a non-formulary drug, the patient’s prescribing
physician or other prescriber, must complete the box below and item 14. You must send information to the
agent immediately in order for it to be considered.
• For an experimental/investigational denial (other than a clinical trial or rare disease treatment) the patient’s
physician must complete items 1-10 and 14.
• For a clinical trial denial, the patient’s physician must complete items 1-9, 11 and 14.
• For an out-of-network service denial (the health plan offers an alternate in-network service that is not
materially different from the out-of-network service), the patient’s physician must complete items 1-10 and
14.
• For an out-of-network referral denial (the health plan does not have an in-network provider with the
appropriate training and experience to meet the health care needs of the patient), the patient’s physician
must complete items 1 - 9, 13 and 14.
• For a rare disease denial, a physician, other than the treating physician, must complete items 1-9, 12 and 14.
1. Name of Physician (or Prescriber)
completing this form:
To appeal an experimental/investigational, clinical trial, out-of-network service, or out-of-network referral denial, the
physician must be licensed and board-certified or board-eligible and qualified to practice in the area of practice
appropriate to treat the patient. For a rare disease appeal, a physician must meet the above requirements but may
not be the patient’s treating physician.
6 EA 09/18
2. Physician (or Prescriber) Address:
Street:
City: State: Zip Code:
3. Contact Person:
4. Phone Number: ( ) Fax: ( )
5. Physician (or Prescriber) Email:
6. Name of Patient:
7. Patient Address:
8. Patient Phone Number:
9. Patient Health Plan Name and ID
Number:
10. Experimental/Investigational Denial or Out-of-Network Service Denial
(Complete this section for an experimental/investigational denial or an out-of-network service denial only. DO NOT
complete this item for appeal of clinical trial participation, rare disease, or an out-of-network referral denial.)
a. For an Experimental/Investigational Denial:
As the patient’s physician I attest that (select one without altering):
OR
Standard health services or procedures have been ineffective or would be medically inappropriate.
There does not exist a more beneficial standard health service or procedure covered by the health plan.
AND
I recommended a health service or pharmaceutical product that, based on the following two documents
of medical and scientific evidence outlined in c and d below, is likely to be more beneficial to the
patient than any covered standard health service.
b. For an Out-of-Network Service Denial
As the patient’s physician I attest that the following out-of-network health service (identify service):
is materially different from the alternate in-network health service recommended by the health plan and (based on
the following two documents of medical and scientific evidence) is likely to be more clinically beneficial than the
alternate in-network health service and the adverse risk of the requested health service would likely not be
substantially increased over the alternate in-network health service.
c. List the documents relied upon and attach a copy of the documents:
Document #1 Title:
Publication Name: Issue Number: Date:
Document #2 Title:
Publication Name Issue Number: Date:
7 EA 09/18
d. Supporting Documents
The medical and scientific evidence listed above meets one of the following criteria (Note: peer-
reviewed literature does not include publications or supplements sponsored to a significant
extent by a pharmaceutical manufacturing company or medical device manufacturer.)
Check the
applicable
documents:
Peer-reviewed medical literature, including literature relating to therapies reviewed and
approved by a qualified institutional review board, biomedical compendia and other
medical literature that meet the criteria of the National Institute of Health’s National
Library of Medicine for indexing in Index Medicus, Excerpta Medicus, Medline and
MEDLARS database Health Services Technology Assessment Research;
Document #1
Document #2
Peer-reviewed scientific studies published in, or accepted for publication by, medical
journals that meet nationally recognized requirements for scientific manuscripts and that
submit most of their published articles for review by experts who are not part of the
editorial staff;
Document #1
Document #2
Peer-reviewed abstracts accepted for presentation at major medical association meetings;
Document #1
Document #2
Medical journals recognized by the Secretary of Health and Human Services, under Section
1861(t)(2) of the federal Social Security Act;
Document #1
Document #2
The following standard reference compendia: (i) the American Hospital Formulary Service
Drug Information; (ii) the National Comprehensive Cancer Network’s Drugs and Biological
Compendium; (iii) the American Dental Association Accepted Dental Therapeutics; (iv)
Thomson Micromedex DrugDex; or (v) Elsevier Gold Standard’s Clinical Pharmacology; or
other compendia as identified by the Secretary of Health and Human Services or the
Centers for Medicare & Medicaid Services; or recommended by review article or editorial
comment in a major peer reviewed professional journal;
Document #1
Document #2
Findings, studies, or research conducted by or under the auspices of federal government
agencies and nationally recognized federal research institutes including the federal Agency
for Health Care Policy and Research, National Institutes of Health, National Cancer
Institute, National Academy of Sciences, Health Care Financing Administration,
Congressional Office of Technology Assessment, and any national board recognized by the
National Institutes of Health for the purpose of evaluating the medical value of health
services.
Document #1
Document #2
11. Clinical Trial Denial
There exists a clinical trial which is open and for which the patient is eligible and has been or will likely be
accepted.
Although not required, it is recommended you enclose clinical trial protocols and related information. The clinical
trial must be a peer-reviewed study plan which has been: (1) reviewed and approved by a qualified institutional
review board, and (2) approved by one of the National Institutes of Health (NIH), or an NIH cooperative group or
center, or the Food and Drug Administration in the form of an investigational new drug exemption, or the federal
Department of Veteran Affairs, or a qualified non-governmental research entity as identified in guidelines issued by
individual NIH Institutes for Center Support Grants, or an institutional review board of a facility which has a
multiple project assurance approved by the Office of Protection from Research Risks of the NIH.
8 EA 09/18
12. Rare Disease Treatment Denial
If provision of the service requires approval of an Institutional Review Board, include or attach the approval.
As a physician, other than the patient’s treating physician, I attest the patient has a rare condition or disease
for which there is no standard treatment that is likely to be more clinically beneficial to the patient than the
requested service. The requested service is likely to benefit the patient in the treatment of the patient’s rare
disease, and such benefit outweighs the risk of the service.
I do I do not have a material financial or professional relationship with the provider of the service (check one).
Check one:
The patient’s rare disease currently or previously was subject to a research study by the National
Institutes of Health Rare Diseases Clinical Research Network.
The patient’s rare disease affects fewer than 200,000 U.S. residents per year.
13. Out-of-Network Referral Denial
As the patient’s attending physician, I certify that the in-network health care provider(s) recommended by the health
plan do not have the appropriate training and experience to meet the particular health care needs of the patient. I
recommend the out-of-network provider indicated below, who has the appropriate training and experience to meet
the particular health care needs of the patient and is able to provide the requested health service.
Name of out-of-network provider:
Address of out-of-network provider:
Training and experience of
out-of-network provider:
(e.g., board certification, years
treating the condition, # of
procedures performed and
outcome, any other pertinent
information).
14. Physician (or Prescriber) Signature
I attest that the above information is true and correct. I understand that I may be subject to professional disciplinary
action for making false statements.
Signature of Physician
(or Prescriber):
Date:
Physician (or
Prescriber) Name:
(Print Clearly):
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NEWYORKSTATEEXTERNALAPPEALAPPLICATION Completeandsendthisapplicationwithin4monthsoftheplansfinaladversedeterminationforhealthservicesifyou arethepatientorthepatientsdesignee,orwithin60daysifyouareaproviderappealingonyourownbehalftoDFS. Mailto:NewYorkState

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Completed 15 February 2022

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