How Providers Can Submit an Appeal
Practitioners and providers may request a review of a claims decision using the Provider Review Form (PRF).
Appeals on Behalf of a Member
If a provider is appealing a decision on behalf of a member, check the box “Provider on Behalf of Member Appeal” on the Provider Review Form. You must also complete the form Physician/Provider Designation Form for Appeals, Grievances or Complaints. The form must be signed and dated by the member after the claim has been processed and denied by CDPHP. By using this form, your request will no longer be considered a provider appeal but would follow the path of a member appeal utilizing/exhausting the member appeal rights.
Appeals of Claims Denied as Experimental, Investigational, or Not Medically Necessary
Providers may file an appeal in writing on their own behalf when a concurrent or retrospective claim is denied as experimental, investigational, or not medically necessary. Such appeals must be submitted within 180 days from the date of notification of denial, utilizing the Provider Review Form. Select the box indicating “Medical Necessity Denial.” We will acknowledge the appeal and if additional information is needed from your office to complete the review, we will request that information within 15 days. CDPHP will complete the review of the appeal within 60 days from receipt.
Commercial Group Coverage and State-Subsidized Plans
If we uphold the initial medical necessity, experimental, or investigational decision for an HMO or CDPHP Universal Benefits, Inc. member, a final adverse determination (FAD) letter will be issued indicating external appeal rights. Select Plan and Family Health Plus members may also have Fair Hearing rights, which will be indicated in the FAD letter.
Medicare, Federal Employees Health Benefits Program (FEHBP), and Self-Insured Groups
If we uphold the initial medical necessity, experimental, or investigational decision for a member of CDPHP Medicare Choices, the Federal Employees Health Benefits Program, or a self-insured group, a determination letter will be issued. This letter represents your final level of appeal review with CDPHP (or its affiliates).
To request an external appeal, the application must be sent to the New York State Insurance Department at:
New York External Appeals
P.O. Box 7209
Albany, NY 12224-0209
The external review agent must receive the application within forty-five (45) days from your receipt of the FAD. CDPHP does not have the authority to extend the 45-day filing period.
A fee of $50 is required from providers requesting an external appeal. You must enclose a check or money order payable to CDPHP as part of your application to the Insurance Department. Your check or money order will be returned if the appeal is decided in your favor.
The external review agent will make a written decision within 30 days of his or her receipt of your appeal. If the agent requests additional information within that 30-day period, the agent has an additional five business days to make a decision. The external review agent will notify you of the decision within two business days of making its decision.
Since January 2010, when a provider files an external appeal concerning a “concurrent” utilization determination and the CDPHP determination is wholly upheld, the provider bears the entire cost of the appeal. If the appeal decision is upheld in part, CDPHP and the provider split the cost of the appeal evenly.
If the external agent upholds a denial for concurrent services that was filed by a provider on behalf of the member, the provider is prohibited from seeking payment from the member other than the copayment, coinsurance, or deductible that would be applicable if the care had been approved.
Please be aware that once you have exercised your external appeal rights for a medical necessity, experimental or investigational denial, the appeal process is then exhausted.