External Appeal Agent definition

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. 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 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 or Preferred 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 Sec...

External Appeal Agent means an entity certified by the superintendent pursuant to Section 4911 of the New York Insurance Law.

Examples of External Appeal Agent in a sentence

• If We have denied coverage on the basis that a service is not Medically Necessary (including appropriateness, health care setting, level of care or effectiveness of a Covered benefit); or is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You or Your representative may appeal that decision to an External Appeal Agent, an independent third party certified by the State to conduct these appeals.

• If We have denied coverage on the basis that the service is not Medically Necessary, You may appeal to an External Appeal Agent if You meet the requirements for an external appeal in paragraph “A” above.

• 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.

• If You meet the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.

• If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Policy.

• In general, the External Appeal Agent must make a decision within 30 days of receipt of Your completed application.