External Review Laws
Independent External Appeal
As of July 1, 1999, health care consumers have even greater protection under New York State law. The state’s external appeal law gives consumers the right to have an external appeal agent (an independent panel of medical experts) review certain health plan decisions about health care services to determine that they are medically necessary. New York's external appeal law allows health care consumers to seek this impartial review in any case where a health plan denies coverage for care it determines is not medically necessary or when a health plan denies a treatment or service because it is experimental or investigational in nature. In such cases, the consumer can file an application with the state Department of Financial Services requesting that an external appeal agent review the case.
By their very definition, experimental treatments have not yet been established as standard care. HMOs and other health plans often participate in clinical trials designed to test the effectiveness of experimental and investigational procedures. However, most health plans have strict criteria relating to coverage of these procedures.
It is important to remember that “newest” doesn't always mean most appropriate. To help make those determinations, a patient (or someone acting on behalf of the patient) has the right to seek an external appeal of a plan's denial of coverage on the basis that the plan considers the treatment experimental or investigational.
The external appeal law seeks to build consumer confidence about managed care by ensuring consumers have access to an independent review process to determine if a particular health care service is medically necessary and appropriate.