New to helping someone in New York?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
New York law gives you an internal appeal with the utilization review agent or insurer first in most cases, then a right to external review through the Department of Financial Services (DFS) and an independent appeal agent.
For steps that work in every state, read these general guides first, then return here for New York rules:
What is different in New York?
- NY State of Health: New York's state Marketplace at nystateofhealth.ny.gov. Dozens of qualified health plans statewide—major issuers include EmblemHealth, Fidelis Care, Healthfirst, MVP, MetroPlus, Oscar, and UnitedHealthcare of New York (availability varies by county).
- Prior authorization (Insurance Law § 4903): § 4903 — 3 business days standard / 72 hours urgent; missed deadlines → deemed approved for PA and step-therapy overrides; no PA for formulary HIV antiretrovirals including PrEP (effective December 25, 2024).
- Internal appeals: At least 45 days to file under § 4904 (many plans allow 180 days); decision within 30 days standard / 2 business days expedited; late decision → adverse determination deemed reversed.
- External review: File with DFS within four months of final denial (DFS external appeal); 30 days standard / 72 hours expedited (24 hours for some non-formulary drugs); binding on plan.
- Medicaid managed care: Plan appeal first (often 60 days), then Medicaid fair hearing (often 120 days from final plan denial) or DFS external review for certain medical-necessity disputes—separate paths.
Who is in charge of your plan?
- DFS — Consumer Assistance: External review, complaints, consumer help — dfs.ny.gov. Hotline: 800-342-3736 or 212-480-6400. External appeal expedited fax line: 888-990-3991.
- U.S. Department of Labor: Many self-funded employer plans.
- OTDA / Office of Administrative Hearings: Medicaid fair hearings after managed care plan appeals.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.