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

• Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, We will only Cover the cost of services required to provide treatment to You according to the design of the trial.

• The External Appeal Agent must notify You in writing of its decision within two (2) business days.

• 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.

• The External Appeal Agent must also notify You in writing of its decision.

• 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 the External Appeal Agent overturns Our decision that a service is not Medically Necessary or approves coverage of an experimental or investigational treatment, We will provide coverage subject to the other terms and conditions of this Contract.

• Immediately after reaching a decision, the External Appeal Agent must notify You and Us by telephone or facsimile of that decision.

• In that case, the External Appeal Agent must make a decision within 72 hours of receipt of Your completed application.

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