EXTERNAL APPEAL: PATIENTS

TIPS FOR PATIENTS FILING EXTERNAL APPEALS (PARITY)

  • Get a letter of support from your treating provider with supporting medical records.
  • If you are filing an external appeal/review with the NY Dept. of Financial Services (DFS), use the External Appeal Application (available on the DFS website) and attach this Sample Letter. You may submit the external appeal/review by fax or by certified or registered mail. If you are filing an expeditedexternal appeal/review, you must also call DFS at (888) 990-3991 and tell them you are doing so. For more information, visit:
  • If you are filing an external appeal/review with an Independent Review Organization (IRO), ask your health plan and the IRO how to file an external appeal/review. You can modify this sample letter and include it with your external appeal/review.

SAMPLE PATIENT EXTERNAL APPEAL (PARITY)

[If Urgent Appeal, write URGENT/EXPEDITED APPEAL]

[Date]

[Your Name]

[Your Address]

New York Department of Financial Services

P.O. Box 7209

Albany, NY 12224-0209

Fax: (800) 332-2729

Re:Attachment to External Appeal Application

Patient’s Name: [Patient’s Name]

Patient’s Health Plan: [Patient’s Health Plan]

Patient’s Provider: [Name and Phone # of Doctor and/or Hospital]

To Whom It May Concern:

I am writing to appeal my health plan’s denial of the coverage or payment for [Insert Description of Denied Service]. [If urgent: I have an urgent health situation and I am filing an expedited appeal pursuant to my rights under state and federal law.] [Denied Service] is medically necessary, and are not experimental or investigational. Please see the enclosed letter from my treating provider for additional explanation.

Furthermore, my health plan’s denial coverage or payment for the above-referenced services appears to violate the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“federal parity law”).[i] The federal parity law requires health insurance plans that provide substance use disorder and mental health benefits to provide them at parity with other medical and surgical benefits. [If patient’s plan is protected by New York State law (see Section 6): New York State also has laws requiring health plans to cover substance use disorder and mental health benefits at parity with other medical and surgical benefits, and {Name of Patient’s Health Insurance Plan} appears to be violating those laws as well.]

[If Patient’s Plan Has an Annual or Lifetime Limit for SUD/MH Benefits: The Affordable Care Act forbids health plans from placing annual or lifetime limits on anything considered an “essential health benefit.” In New York, inpatient and outpatient mental health and substance use disorder treatment are considered “essential health benefits.” Therefore, {Name of Patient’s Health Insurance Plan} is violating the Affordable Care Act by placing annual or lifetime limits on {Insert Treatment Type}.]

[Now Tell Your Story: Describe your mental health or substance use disorder and the treatment you need. Explain what happens when you do not have treatment and why it is important that you receive the treatment.]

[If Plan Did Not Provide Documents/Information You Requested: My plan also violated the federal parity law’s (and other laws’) requirement that it disclose certain information to me upon request. On {Date(s)} I requested that my plan provide me with {Insert Description of Documents/Information You Requested}, which it is required by law to provide. The plan did not provide this information to me.]

I respectfully request that you overturn my health plan’s adverse benefit determination and require it to cover [Denied Service]. I also request that you provide me with a written determination as to whether my plan is in compliance with the federal parity law. If you have any questions, you can reach me at [Phone # and/or Email Address].

Sincerely,

[Your Name]

[If You Are Attaching Documentation, Like a Letter from Your Provider: Enclosure]

[i]SeePaul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Pub. L. No. 110-343, §§ 511-512, 122 Stat. 3881 (2008); Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Technical Amendment to External Review for Multi-State Plan Program, 78 Fed. Reg. 68239 (Nov. 13, 2013) (to be codified at 45 C.F.R. pts. 146, 147); The Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care Organizations, the Children’s Health Insurance Program (CHIP), and Alternative Benefit Plans, 80 Fed. Reg. 19418 (proposed Apr. 10, 2015) (to be codified at 42 C.F.R. pts. 438, 440 456, et al.).