New York external review

External appeal (DFS)File within 120 daysFee: Up to $25 (capped at $75/plan year) — refunded if you win, waived for Medicaid/Child Health Plus or hardshipExpedited: 72 hours (24 hours for non-formulary drug denials)

New York's external appeal covers unusually broad ground — medical necessity, experimental treatment, clinical trials, rare diseases, out-of-network denials, formulary exceptions, and step-therapy overrides. Decisions bind the plan, the state publishes a searchable database of past appeal outcomes, and DFS's own data shows roughly 44% of consumer appeals reversed in whole or part.

Who to contact

NY Department of Financial Services (DFS)

www.dfs.ny.gov/complaints/file_external_appeal

1-800-400-8882

Authority: NY Insurance Law Article 49 (§ 4910 et seq.)

Deadlines and decision timelines

Your filing window: 120 days from the final internal denial.
Standard review decided in: 30 days (72 hours for non-formulary drug denials)
Expedited review decided in: 72 hours (24 hours for non-formulary drug denials) — hospitalization, emergency services, or your physician attests that delay would pose a serious threat to your health
Cost to you: Up to $25 (capped at $75/plan year) — refunded if you win, waived for Medicaid/Child Health Plus or hardship

How to file, step by step

Get your final adverse determination. Finish the plan's internal appeal (or obtain a waiver). You then have 4 months to file — providers filing on their own behalf get 60 days.
Search the outcome database first. DFS publishes every external appeal outcome, searchable by plan, diagnosis, and treatment. Find reversals matching your denial and echo their reasoning.
File online or on paper. Online through the DFS portal (myportal.dfs.ny.gov), or the fillable application by email, fax, or certified mail to the DFS Albany office. Help line: 1-800-400-8882.
The external appeal agent decides. 30 days standard, 72 hours expedited, 24 hours for urgent non-formulary drug cases. The decision is binding on your plan.

Who can use it

NY-regulated (fully-insured) plans including HMOs, EPO/PPO plans, and Medicaid managed care — for medical necessity, experimental/investigational, clinical trial, rare disease, out-of-network, formulary exception, and step-therapy denials.
Not eligible: self-funded employer (ERISA) plans — those use the federal external review process.

What to know

The $25 fee is refunded if the denial is overturned — and waived for Medicaid, Child Health Plus, and financial hardship.
New York also lets treating providers file external appeals on their own behalf for retrospective and continued-treatment denials.
DFS's 2023 data: consumers won reversal in whole or part in 44.1% of EPO/PPO external appeals (1,841 filed) and 49.5% of HMO appeals.

Denial data from plans operating in New York

Prior-authorization metrics these insurers disclosed for New York contracts under the federal CMS-0057-F transparency rule (CY2025, insurer-published). A high denial rate paired with a high appeal-overturn rate is the profile worth appealing. Full methodology: insurer denial rates.

Insurer	Contract / plan	Line	Requests	Denied	Appeals overturned
Centene	H2775 Wellcare	Medicare Advantage	151,140	16.46%	94.24%
Centene	H4868 Wellcare	Medicare Advantage	90,696	20.84%	92.72%
Centene	H2816 Wellcare	Medicare Advantage	1,635	10.34%	90%
Molina Healthcare	NY-MEDICAID-MLTSS	Medicaid	—	13%	16%
Elevance Health	NY-CHIP Anthem	Medicaid	—	11.6%	42.5%
Highmark	medicaid-ffs-NY	Medicaid	—	8.7%	—
Molina Healthcare	H5992	Medicare Advantage	—	8%	30%
Elevance Health	H3342 Anthem	Medicare Advantage	—	3.7%	75%
Elevance Health	NY-Medicaid Anthem	Medicaid	—	1.2%	40.2%
Molina Healthcare	NY-FIDE	Medicaid	—	0%	—

New York external review FAQ

How often do New York external appeals succeed?

Per DFS's published 2023 data, 44.1% of EPO/PPO external appeals and 49.5% of HMO appeals were reversed in whole or in part — nearly half of consumers who filed got something back.

What does it cost?

Your plan may charge up to $25 per appeal, capped at $75 per plan year. The fee is refunded if the denial is overturned, and waived entirely for Medicaid, Child Health Plus, and financial hardship.

What kinds of denials qualify?

Broader grounds than almost any state: medical necessity, experimental or investigational treatment, clinical trial participation, rare disease treatment, out-of-network services when the network is inadequate, formulary exceptions, and step-therapy overrides.

Can I see past appeal outcomes before filing?

Yes — DFS runs a public, searchable External Appeals Database covering every decided appeal, filterable by health plan, diagnosis, and treatment. Search your denial type, find reversals, and mirror the arguments that won.

How fast is an expedited appeal?

72 hours — and just 24 hours for urgent non-formulary drug denials. Expedited review applies when you're hospitalized, received emergency services, or your physician attests that delay poses a serious health threat.

Primary sources

Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.

Internal appeal first, external review second. We’ll map your path.

Explain my denial