External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. General Dentist: A dentist licensed under Title 8 of the New York State Education Law (or other comparable state law, if applicable) who is not a Specialist.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Participating Providers. The In-Network Deductible applies before any Copayments or Coinsurance are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service. In-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Participating Providers. This limit never includes Your Premium or services We do not Cover. The In-Network Out-of-Pocket Limit only applies to benefits that are part of the pediatric dental essential health benefit. Medically Necessary: See the How Your Coverage Works section of this Policy for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee. New York State of Health (“NYSOH”): The New York State of Health, the Official Health Plan Marketplace. The NYSOH is a marketplace where individuals, families and small businesses can learn about their health insurance options; compare plans based on cost, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; choose a plan; and enroll in coverage. The NYSOH also helps eligible consumers enroll in other programs, including Medicaid, Child Health Plus and the Essential Plan.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. • Is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons; • Has organized departments of medicine and major surgery; • Has a requirement that every patient must be under the care of a Physician or dentist; • Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.); • If located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets at least the standards set forth in 42 U.S.C. Section 1395x(k); • Is duly licensed by the agency responsible for licensing such Hospitals; and • Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care. Hospital does not mean health resorts, spas, or infirmaries at schools or camps.
Examples of External Appeal Agent in a sentence
If the External Appeal Agent determines that the information You submit represents a material change from the information on which We based Our denial, the External Appeal Agent will share this information with Us in order for Us to exercise Our right to reconsider Our decision.
However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State.
The External Appeal Agent may request additional information from You, Your Physician, or Us. If the External Appeal Agent requests additional information, it will have five (5) additional business days to make its decision.
In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application.
If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.
More Definitions of External Appeal Agent
External Appeal Agent means an entity certified by the superintendent pursuant to Section 4911 of the New York Insurance Law.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: • Is primarily engaged in providing, by or under the continuous supervision of Physicians, to patients, diagnostic services and therapeutic services for diagnosis, treatment and care of injured or sick persons; • Has organized departments of medicine and major surgery; • Has a requirement that every patient must be under the care of a Physician or dentist; • Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.); • If located in New York State, has in effect a Hospitalization review plan applicable to all patients which meets at least the standards set forth in 42 U.S.C. Section 1395x(k); • Is duly licensed by the agency responsible for licensing such Hospitals; and • Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care. Hospital does not mean health resorts, spas, or infirmaries at schools or camps. Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Cost-Sharing: Amounts You must pay to a Participating Provider for Covered Services, expressed as Copayments, Deductibles and/or Coinsurance. Medically Necessary: See the How Your Coverage Works section of this Contract for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Copayment: A fixed amount You pay directly to a Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. Medically Necessary: See the How Your Coverage Works section of this Policy for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee. New York State of Health (“NYSOH”): The New York State of Health, the Official Health Plan Marketplace. The NYSOH is a marketplace where individuals, families and small businesses can learn about their health insurance options; compare plans based on cost, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; choose a plan; and enroll in coverage. The NYSOH also helps eligible consumers enroll in other programs, including Medicaid, Child Health Plus and the Essential Plan. Non-Participating Provider: A Provider who doesn’t have a contract with Us to provide services to You. The services of Non-Participating Providers are Covered only for Emergency Dental Care or when authorized by Us. Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services. This limit never includes Your Premium, Balance Billing charges or the cost of dental care services We do not Cover.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Copayment: A fixed amount You pay directly to a Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service. In-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Participating Providers. The In-Network Deductible applies before any Copayments or Coinsurance are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services received from Participating Providers. This limit never includes Your Premium or services We do not Cover. The In-Network Out-of-Pocket Limit only applies to benefits that are part of the pediatric dental essential health benefit.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Copayment: A fixed amount You pay directly to a Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service. Medically Necessary: See the How Your Coverage Works section of this Contract for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee. New York State of Health (“NYSOH”): The New York State of Health, the Official Health Plan Marketplace. The NYSOH is a marketplace where individuals, families and small businesses can learn about their health insurance options; compare plans based on cost, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; choose a plan; and enroll in coverage.
External Appeal Agent. An entity that has been certified by the New York State Department of Financial Services to perform external appeals in accordance with New York law. Grievance: A complaint that You communicate to Us that does not involve a Utilization Review determination. Hospital: A short term, acute, general Hospital, which: Hospitalization: Care in a Hospital that requires admission as an inpatient and usually requires an overnight stay. In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the Covered Service that You are required to pay to a Participating Provider. The amount can vary by the type of Covered Service. In-Network Deductible: The amount You owe before We begin to pay for Covered Services received from Participating Providers. The In-Network Deductible applies before any Copayments or Coinsurance are applied. The In-Network Deductible may not apply to all Covered Services. You may also have an In-Network Deductible that applies to a specific Covered Service that You owe before We begin to pay for a particular Covered Service. Medically Necessary: See the How Your Coverage Works section of this Contract for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been