What is external review?
External review is an independent review of certain final denials. The New York Department of Financial Services (DFS) receives your application and assigns a certified external appeal agent(independent review organization) such as IPRO, IMEDECS, or MCMC to review medical records and decide whether the plan's denial should stand.
The appeal agent is not your insurance company. The agent's decision is binding on you and the plan for eligible cases.
General overview: Appeals roadmap. Complete New York internal appeals first unless an urgent exception applies.
DFS publishes summaries of past external appeal decisions that may help with your case: searchable external appeals database.
Who can use New York review?
External review generally applies when:
- You have a New York-regulated health plan (fully insured commercial, qualified health plans, and many Medicaid managed care plans)
- The dispute involves medical necessity, experimental/investigational treatment, or certain out-of-network referrals or services
- You received a final adverse determination after internal review (with exceptions below)
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Original Medicare and Medicare Advantage (federal Medicare appeals)
- No Surprises Act balance-billing disputes—only the patient or patient designee may file external review, not the provider alone
Deadlines & exhaustion
Four-month filing window (patients)
Patients and patient designees must submit the DFS external appeal application within four monthsof the plan's final adverse determination (DFS external appeal).
60 days for providers appealing on their own behalf
Health care providers appealing on their own behalf (not as the patient's designee) generally have 60 days from the final adverse determination.
Exhaust internal appeal first
Complete required internal appeal levels before external review in most cases. Exceptions include:
- You and the plan jointly agree to waive internal review (10 NYCRR § 98-2.3)
- The plan fails to meet internal appeal deadlines—determination may be deemed reversed under § 4904(e)
- Expedited external review may run at the same time as expedited internal review when urgent (DFS instructions)
You may submit additional information to the appeal agent within 45 days of the final denial if the agent has not yet decided (10 NYCRR § 98-2.3).
How to file
- Complete internal appeal and obtain a final adverse determination when required.
- Gather the denial letter, appeal correspondence, policy, and medical records.
- Complete the New York State External Appeal Application from dfs.ny.gov/complaints/file_external_appeal (helpful hints).
- Mark expedited review if urgent and complete the physician certification sections.
- For expedited appeals, call 888-990-3991 when you fax the application (per DFS form instructions).
Free help filing: Community Health Advocates at 888-614-5400.
Links hub: New York external appeals links.
How long it takes
- Standard appeal: appeal agent decision within 30 days
- Standard formulary exception: within 72 hours
- Expedited appeal: within 72 hours
- Expedited non-formulary drug: within 24 hours
DFS reviews your application for completeness before assigning an appeal agent.
Is the decision binding?
For eligible disputes, the external appeal agent's decision is binding on the patient and the health plan (DFS). If the agent overturns the denial, the plan must cover the service consistent with the decision.
Medicaid & Medicare
Medicaid managed care: plan appeal to a Final Adverse Determination, then either a Medicaid fair hearing (often 120 days) or DFS external review for certain medical-necessity denials—your FAD notice explains which paths apply.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.