Consumers have the right to an external appeal when health care services are denied by an HMO or insurer (health plan) as not medically necessary, experimental / investigational, a clinical trial, a rare disease treatment, or, in certain cases, as out-of-network.

Providers have their own right to an external appeal when these health care services are denied concurrently or retrospectively.

External appeal requests must be submitted to the New York State Insurance Department and the Department will assign independent medical experts to review the appeal.