Adverse determinations will only be made by a clinical peer reviewer of AHP when requested health
services or a level of care are denied because they fail to meet the established written utilization review
criteria of the plan for medical necessity and appropriateness of the level of care.
A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice
medicine, or a healthcare professional other than a licensed physician who, where applicable, possesses a
current and valid non-restricted license, certification or registration or, where no provision for a license,
certificate or registration exists, is credentialed by the national accrediting body appropriate to the
profession and is in the same profession/specialty as the healthcare provider who typically manages the
Notices of adverse determination are made in writing and include:
- The reasons for the determination
- The clinical rationale, if any,
- Instructions on how to initiate an appeal
- Notice of availability of the clinical review criteria upon which the determination was
based, upon request of the member or the memberís designee,
- Specification of any additional information which should be provided to, or obtained by
the plan in order to render a decision on the appeal. As a member you have the right to
designate a representative to file an appeal. Only qualified clinical personnel will review
You, your designee, or your healthcare provider may request from AHP a reconsideration or appeal of the
adverse determination. Various types of appeals and time frames for responses are provided for,
depending on the following circumstances under which the adverse determination was made:
- Reconsideration within one (1) business day of receipt of the request;
- Expedited appeal with access to a clinical peer reviewer within one (1) business day and a
determination completed in two (2) business days of receipt of necessary information to
conduct the appeal.
- Standard appeal with a determination completed within sixty (60) days of receipt of
necessary information to conduct the appeal. AHP will issue written notification of the
appeal determination within two (2) business days.
- Retrospective review determination is made within thirty (30) days of receipt of necessary
information with which to render the decision.
Failure by AHP to make an appeal determination within the applicable time periods set forth in Article 49
of the Public Health Law shall be deemed to be a reversal of AHPís initial adverse determination.
Internal Appeal Procedures
1. Except in cases of adverse determinations made during retrospective review, when an adverse
determination is made without attempting to discuss the plan of care with the healthcare provider who
specifically recommended the healthcare service, procedure or treatment under review, the provider may
request a reconsideration of the adverse determination.
Reconsideration will occur within one (1) business day of receipt of the request, and will be conducted
between the memberís healthcare provider and the clinical peer reviewer who made the initial
determination (or a designated substitute if the original reviewer is not available).
If the adverse determination is upheld after reconsideration, AHP will issue a written notice of adverse
determination within one (1) business day after the determination. The member or the memberís designee
or the memberís healthcare provider may then proceed to further appeal the decision using either the
expedited appeal or the standard appeal, as defined below.
2. Except in cases of adverse determinations made during retrospective review, an Expedited Appeal is
allowed in situations involving:
a. Continued or extended healthcare services, procedures or treatments or additional services for a
member undergoing a course of continued treatment prescribed by a healthcare provider;
b. The healthcare provider believes an immediate appeal is warranted. AHP will provide the memberís
healthcare provider with reasonable access within one (1) business day of receiving notice of the taking of
an expedited appeal, to a clinical peer reviewer other than the clinical peer reviewer who rendered the
The clinical peer reviewer will render a determination within two (2) business days of receipt of necessary
information to conduct the appeal.
Expedited appeals, which do not result in a resolution satisfactory to the appealing party, may be further
appealed through the standard appeal process, as defined below, or a request can be made for an external
appeal (refer to page 21ĖExternal Appeal Procedure)
3. Except in cases of adverse determinations made during retrospective review, a Standard Appeal process
is required in all other situations than those described above.
These appeals may be filed in writing or by telephone. To file a standard appeal of an adverse
determination, an appealing party has no less than forty-five (45) days after the member receives a notice
of adverse determination and AHP receives all necessary information to conduct the appeal.
AHP will send written acknowledgment of receipt of the appeal to the appealing party within fifteen (15)
days of the date of the appeal. AHP will assign a clinical peer reviewer other than the one who rendered
the adverse determination, and the appeal determination will be rendered within sixty (60) days of receipt
of information necessary to conduct the appeal.
Thereafter, AHP will issue written notification of the appeal determination within two (2) business days
to the member, the memberís designee and the memberís healthcare provider. This notice will include
reasons for the determination, with the clinical rationale provided where the adverse determination is
upheld on the appeal and notice of the memberís right to external appeal and the timeframes for such
4. Retrospective review determinations involve services, which have already been delivered to the
member. An appeal or reconsideration of adverse determinations of this type will comply with the
procedures of the standard appeal except that the appeal determination must be made within thirty (30)
days of receipt of information necessary to conduct the appeal. AHP will assign a clinical peer reviewer
other than the one who rendered the adverse determination.
External Appeal Procedure
You may file an application for an external appeal by a state approved external appeal agent if you have
received a denial of coverage based on medical necessity or because the service is experimental and/or
To be eligible for an external appeal, you must have received a final adverse determination (FAD) as a
result of AHPís first-level utilization review (UR) appeal process or both you and AHP must jointly agree
to waive the UR appeal process. An external appeal application will be attached to the FAD that you
receive from the Plan.
The application will provide clear instructions for completion. You must include $50.00 with the
application. Your healthcare provider may not charge you for this fee. This money will be refunded if the
external appeal is decided in your favor. You may obtain a waiver of this fee if you meet AHPís criteria
for a hardship exemption. To apply for this exemption, please call our Member Services Department at
The external appeal application will instruct you to send the completed form to the New York State
Department of Insurance. You (and your doctors) must release all pertinent medical information
concerning your medical condition and request for services. An independent external appeal agent
approved by the State will review your request to determine if the denied service is medically necessary
and should be covered by AHP. All external appeals are conducted by clinical peer reviewers certified by
the State. The agentís decision is final and binding on both you and AHP.
The application for external appeal must be made within forty-five (45) days of your receipt of the notice
of final adverse determination as a result of AHPís first-level appeal process, or within forty-five (45)
days of when you and AHP jointly agree to waive the internal appeal process. The Plan does not require
you to exhaust the second level of appeal to be eligible for external appeal.
However, regardless of whether you participate in this additional AHP internal appeal process, an
application for external appeal must be filed with the New York State Department of Insurance within
forty-five (45) days from your receipt of the notice of final adverse determination from AHPís first-level
appeal to be eligible.
You will lose your right to an external appeal if you do not file an application for an external appeal
within forty-five (45) days from your receipt of the final adverse determination from the first level
internal plan appeal.
An external appeal agent must decide a standard appeal within thirty (30) days of receiving your
application for external appeal from the state. Five (5) additional business days may be added if the agent
needs additional information. If the agent determines that the information submitted to it is materially
different from that considered by AHP, AHP will have three (3) additional business days to reconsider or
affirm its decision. You and AHP will be notified within two (2) business days of the agentís decision.
You may request an expedited appeal if your doctor can attest that a delay in providing the recommended
treatment would pose an imminent or serious threat to your health. The external appeal agent will make a
decision within three days for expedited appeals. Every reasonable effort will be made to notify you and
AHP of the decision by telephone or fax immediately. This will be followed immediately by a written
In the event an adverse determination is overturned on external appeal, or in the event that AHP reverses
a denial, which is the subject of external appeal, AHP shall provide or arrange to provide the healthcare
service(s), which is the basis of the external appeal to you.
If you are no longer insured by AHP at the time of an external appeal agentís reversal of AHPís
utilization review denial, AHP will not be required to provide any healthcare services to you. You, your
designee or your healthcare provider, may request an external appeal of a retrospective adverse
determination if the services in question were denied based on medical necessity and/or were considered
experimental and/or investigational.
Contact Information for External Appeals:
- The New York State Department of Insurance at 800-400-8882, or its website
- The New York State Department of Health website only (www.health.state.ny.us) or
- Our Member Services Department at 866-747-8422.