Health Insurance and Managed Care Appeals and Grievances for Patients Under the New York Managed Care Reform Act. This article discusses patient appeals from health plan decisions in New York under current law. Click on our link to Information About Health Plan and Managed Care Appeals and Grievances in Other States. TABLE OF CONTENTS
This article gives a brief overview of the appeal systems available to patients enrolled in managed care health plans such as health maintenance organizations ("HMOs") regulated by New York State under the 1996 Managed Care Reform Act. It then discusses how a patient can appeal a decision by their managed care health plan to deny coverage for a medical service on the grounds that the service is not, in the health plan’s judgment, "medically necessary" - a so-called "utilization review" denial. WHAT CAN PATIENTS APPEAL UNDER THE MANAGED CARE REFORM ACT? The Managed Care Reform Act provides two ways a patient can challenge decisions by their managed care plan. The first of these applies to decisions by plans to deny claims for services on the grounds that the services are not "medically necessary" These can be challenged by filing an APPEAL. Patients can challenge other decisions by managed care plans by filing a GRIEVANCE. Examples of decisions which can be grieved include denials of referrals to specialists and denials (other than utilization review denials) of services on the grounds that they are not covered under a patient's insurance contract. APPEALS and GRIEVANCES are similar although there are differences between them. Health plans must give their members detailed information about both. This information should be in the member handbook or insurance contract. If you can’t find it, contact your health plan and find out where it is. Don’t wait until you have a claim denied to become familiar with your plan’s APPEAL and GRIEVANCE procedures. Make sure you understand these procedures and keep them in a place where they can be easily found, including where to file APPEALS and GRIEVANCES and who at your health plan to contact for information. WHO IS COVERED BY THE MANAGED CARE REFORM ACT? The 1996 New York Managed Care Reform Act DOES NOT COVER ALL NEW YORKERS. It is important for you to know if you are covered so check with someone knowledgeable about your managed care health plan to see if you are. Most health insurance plans, whether they are provided by HMOs or traditional insurers, exclude coverage for services which are medically unnecessary. The process by which a health plan determines whether or not a service is "medically necessary" for a patient is known an "utilization review". Utilization review can occur either before or after the patient receives a service. In the case of expensive treatments such as inpatient surgery, it is quite common for a health plan to require that the utilization review be performed prior to treatment. If the health plan requires that the patient obtain the plan’s prior approval for the service and the patient fails to do so, the plan may refuse to pay for the treatment even if it would have covered the service if the patient had requested approval on a timely basis. Different plans require prior approval for different services. In addition, although the standard for "utilization review" decisions is whether the service is "medically necessary", there is no uniform definition of "medically necessary". Each health plan can have its own definition. Since the failure to meet utilization review requirements can result in a lack of coverage, it is very important that patients familiarize themselves with these requirements. Make sure you have a list of services requiring prior approval from your plan. Under the 1996 Managed Care Reform Act, your plan must give you this information. It should be in your member handbook or insurance contract. If it is not there or if you have any questions about the information you have been given, contact your health plan. Keep the list of required approvals in a handy place and make sure you check it before going to the doctor or hospital. Otherwise you may find yourself in a situation in which your health plan denies coverage for a service and the doctor or hospital seeks payment directly from you for the amount you would otherwise expect your health plan to pay. In the case of services for which prior approval is required, your health plan must, under the Managed Care Reform Act, give or deny approval within 3 business days of receiving the information it needs to make the decision. Both you and your physician must be given notice of the plan’s decision by telephone and in writing. In addition, if you are receiving services for which you already obtained a prior approval and need to get an additional approval to continue receiving the services, for example, an extension of a hospital stay, the plan must make its decision within one business day of receipt of the necessary information. However, under these circumstances, the plan can send the notice of its decision directly to your hospital or physician so you may want to check with them about the status of your approval. APPEAL OF UTILIZATION REVIEW DECISIONS. If a health plan decides that a service is not "medically necessary", you can appeal this decision. Prior to July 1, 1999, patients only had the right to appeal the decision to a physician or other qualified health care practitioner selected by the plan. However, under a new law, which became effective July 1, 1999, patients have the right to appeal utilization review decisions to reviewers who are independent of their health plan. This right to an independent review will also be available if a health plan denies coverage for a treatment on the grounds that it is "experimental or investigational". See our article on External Review for more information. The procedures for filing a utilization review appeal should be included in your member handbook or contract or other written information given to you by your health plan. There are 2 categories of utilization review appeals: expedited and standard. Any utilization review decision can be appealed though a standard appeal. The health plan can establish a deadline for filing a standard appeal which can be no less than 45 days after the patient receives notice of the utilization review decision being appealed. Expedited appeals are available on a more limited basis. A patient is eligible to file an expedited appeal if (1) the patient is currently receiving a course of treatment and the patient’s health plan denies approval of a continuation of the treatment, for example an extension of a hospital stay; or (2) the hospital, physician or other health practitioner providing services believes an immediate appeal is necessary. As soon as you receive a claim determination from your health plan review it and decide whether you want to file an appeal. Make sure you know what your deadlines are. Don’t wait until the last minute. Expedited appeals must be decided within 2 business days of the health plan’s receipt of information needed to decide the appeal. Standard appeals must be decided within 60 days of the health plan’s receipt of the information needed to conduct the appeal. The plan must provide written notice of the decision in a standard appeal within 2 business days of the decision. If a patient’s expedited appeal is denied, the patient has the right to file a standard appeal. INFORMATION TO ASSIST PATIENTS IN FILING APPEALS. To assist patients in preparing and filing appeals, the Managed Care Reform Act requires health plans to provide patients with certain information, including the following. Check to make sure that you receive all of the information to which you are entitled. If you haven’t received it, contact your health plan or the person responsible for administering your health plan. You can also contact the New York State Health Department or Insurance Department. The following lists some of the important categories of information patients are entitled to receive.
The principal sections of the Managed Care Reform Act relating to appeals are contained in the following statutory provisions each of which applies to a different type of health plan. Public Health Law section 4408-a :HMO grievances. Public Health Law section 4904: HMO utilization review decisions . Insurance Law section 4802: grievances involving other types of managed care plans. Insurance Law section 4904: utilization review decisions involving other types of managed care plans . NEW YORK STATE HEALTH AND INSURANCE DEPARTMENTS. If you have any questions about your right to file appeals, ask your health plan now. Or, you can contact the New York State Health Department Hotline at 1-800-206-8125 or the New York State Insurance Department at 1-800-342-3736, 212-480-6400 or 518-474-6600. The New York State Insurance Department's website also provides information on filing a complaint. The New York State Insurance Department includes on its website its Guide to Health Insurers which includes a ranking of insurance plans based on the number of complaints filed against them with the Insurance Department as well as other information such as the numbers of grievances and appeals decided in the consumer's favor.
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