SUBSCRIBE TO PRM TODAY

Question:   I have an employee who is filing a New York State External Appeal. Does the patient’s health plan charge a fee for the external appeal?  For an external appeal, is the person appealing required to pay a fee?

Answer: As we understand it, the health plan may or may not charge a fee for the external appeals process.  That fee is rebated back to the individual if the appeal is successful.  We would recommend that you contact the carrier directly to determine what their specific policy and procedure is for this process.

Specifically, there is an FAQ that directly addresses your question as follows:

Do I Pay A Fee For An External Appeal?  Health plans may charge a $25.00 fee to patients or their designees, not to exceed $75.00 in a single plan year.  The fee is waived for patients who appeal and are covered under Medicaid, Child Health Plus, Family Health Plus, or if the fee will pose a hardship.  Health plans may charge providers a $50.00 fee per appeal.  The fee will be returned to you if the external appeal agent overturns the health plan’s denial.

More information about the process, application forms and frequently asked questions for the New York State External Appeals for Medical Claims process can be found at http://dfs.ny.gov/insurance/extapp/extappqa.htm#standes.