Health insurance denied a claim or care in New York: what to do

Checked against official sources: Oct 31, 2026

In New York:

Internal appeal to your plan
New York law requires plans to give you at least 45 days to file a standard appeal.
Ask for external review
You have 4 months to apply.
Do this now
Read the denial notice. Find the reason and denial code, the deadline to appeal, how to appeal, and who handles external review.

General legal information, not legal advice. RobinClaim is not a law firm.

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Your plan for New York

Do now

  1. Ask your doctor to tell the plan the case is urgent and to request an expedited (fast) appeal. If your doctor says it's urgent, the plan must treat it as urgent.

    Why: Urgent appeals must be decided within 72 hours, and you can ask for an expedited external review at the same time.

  2. Read the denial notice. Find the reason and denial code, the deadline to appeal, how to appeal, and who handles external review.

    Why: The notice must include these. The deadline and the reason decide your next step.

  3. Appeal before the date the cut takes effect, and say you want the treatment to continue during the appeal.

    Why: If a plan wants to cut or stop an approved ongoing treatment, it must tell you in advance so you can appeal first, and coverage must continue while the appeal is pending.

  4. If Medicaid or your Medicaid plan is cutting or stopping a service you get now, appeal (or ask for a fair hearing) and ask to keep your services during the appeal, by the deadline on your notice. For a Medicaid plan appeal, federal rules give you until 10 days after the plan sends the notice or the date the change takes effect, whichever is later; some states give more time.

    Why: Asking in time generally keeps the service going until the decision. If you lose, the state or plan may try to recover the cost.

  5. Ask your Medicaid plan for an expedited (fast) appeal, and ask your doctor to support it. If you also need a state fair hearing, you can ask for an expedited hearing in the same request.

    Why: An expedited plan appeal must be decided within 72 hours (the plan can extend it by up to 14 days in some cases).

  6. Follow the instructions in your Medicare notice for the first appeal level, and call your State Health Insurance Assistance Program (SHIP) for free help (shiphelp.org).

    Why: Medicare and Medicare Advantage have their own appeal process with up to 5 levels; each decision letter tells you how to go to the next level.

This week

  1. Ask the plan, in writing, for a free copy of your claim file and any rule or guideline it used. You can also ask for the diagnosis and treatment codes.

    Why: These are free, and asking for codes doesn't count as starting your appeal.

  2. File the internal appeal in writing before the deadline (federal rules give at least 180 days from when you received the denial). Include a letter from your doctor explaining why you need the care. Keep copies of everything.

    Why: The plan must decide within 72 hours for urgent care, 30 days for care you haven't had yet and 60 days for care you already got.

  3. Find out whether your job-based plan is self-insured: check the plan booklet (summary plan description) or ask HR.

    Why: Self-insured plans are generally overseen by the U.S. Department of Labor (EBSA), not your state insurance department, and generally use the federal external review rules.

  4. If you're in a Medicaid managed care plan, appeal to the plan within 60 calendar days of its notice (orally or in writing).

    Why: The plan must decide within 30 days, or 72 hours if expedited (it can extend by up to 14 days in some cases). If it says no or misses its deadline, you can ask for a state fair hearing.

  5. If the denial came from your state Medicaid agency itself (not a managed care plan), ask for a state fair hearing before your state's deadline (at most 90 days from the notice; check your notice). You can ask for an expedited hearing in the same request.

    Why: Your notice lists the ways your state accepts hearing requests.

  6. Call your state's consumer assistance program or insurance department for free help with the appeal.

    Why: Many states have a Consumer Assistance Program that helps people with health insurance problems, including appeals.

If it's not resolved

  1. Ask for an independent external review before the deadline (at least 4 months under federal rules; your state may allow more). Your final denial letter says where to send it.

    Why: The reviewer must decide within 45 days (72 hours if urgent), and the plan must follow the decision. The federal process is free; a state or plan reviewer can charge at most $25.

  2. If the plan still says no or breaks the rules, file a complaint with your state insurance department (insured plans) or the U.S. Department of Labor's EBSA (self-insured job-based plans).

    Why: Regulators can look into whether the plan followed the law.

  3. If your job-based plan's final denial stands, the notice must tell you about your right to sue under ERISA. Court deadlines can be short, so get legal advice quickly.

    Why: Plans can't require more than two appeal levels before you can sue.

  4. If you lose the Medicaid plan appeal, ask for a state fair hearing within the time your state allows (90 to 120 days from the plan's decision).

    Why: At the hearing you can see your case file, bring witnesses and question the evidence.

  5. If you're being billed while you appeal, ask the provider to hold the bill until the appeal is decided. For a surprise out-of-network bill, call the No Surprises Help Desk at 1-800-985-3059.

    Why: A denial about surprise-billing protections can also go to external review.

  6. Keep a record: denial letters, explanations of benefits, your appeals, and notes of every call (date, time, name and title, what was said). Send copies, keep originals.

    Why: A clear record helps at every level of appeal.

Deadlines

Internal appeal to your plan (job-based or individual plan)

General rule: At least 180 days from when you receive the denial (federal minimum; your plan may allow more). See state for any state rule.

In New York:

New York law requires plans to give you at least 45 days to file a standard appeal. Federal rules give at least 180 days for most plans. The deadline that applies to you is on your denial notice.

Law: N.Y. Ins. Law 4904(b), (c) · checked Oct 2026 · Official source · From Health Appeal Map: New York

Plan's decision on an internal appeal

General rule: 72 hours for urgent care; 30 days for care not yet received; 60 days for care already received (29 CFR 2560.503-1(i))

Official source

Ask for external review

General rule: At least 4 months after you receive the final denial (federal process and minimum for state programs); see state

In New York:

You have 4 months to apply. If your plan offers a second-level internal appeal, you do not have to use it; if you do, the 4 months still run from the first appeal decision. If DFS does not receive your application within 4 months, you cannot get an external appeal. A provider appealing on its own behalf has 60 days.

Law: N.Y. Ins. Law 4910, 4914; DFS, New York State External Appeal · checked Oct 2026 · Official source · From Health Appeal Map: New York

Medicaid managed care plan appeal

General rule: 60 calendar days from the date on the plan's notice (42 CFR 438.402(c)(2)(ii))

Official source

Medicaid state fair hearing

General rule: Set by your state, at most 90 days from the notice (90-120 days after a managed care plan's appeal decision); see state

In New York:

Hearing days
60 days
Hearing days from
The date of the action or notice you disagree with (the notice says "60 days from the date of this notice")

Law: N.Y. Soc. Serv. Law 22(4)(a); 18 NYCRR 358-3.5, 358-3.6; DOH notice OHIP-3868 · checked Oct 2026 · Official source · From Health Appeal Map: New York

Keep Medicaid services during the appeal

General rule: Medicaid plan appeal: ask by the later of 10 days after the plan sends the notice or the date the change takes effect (42 CFR 438.420). State agency action: ask for a hearing before the change takes effect (42 CFR 431.230, 431.231). Some states give more time; see state

In New York:

If the agency had to give you advance notice, your Medicaid continues unchanged until the hearing decision (aid continuing) if you ask for a fair hearing before the effective date of the action on your notice. DOH guidance (GIS 25 MA/07) also accepts a request made within 10 days of the mailing of the notice, if that is later. For a notice from NY State of Health, coverage continues if you ask within 10 days of the date of the notice or before the effective date, whichever is later. If you lose, you may have to pay back the cost of benefits you got while waiting.

Law: N.Y. Soc. Serv. Law 22(4)(a); 18 NYCRR 358-3.5, 358-3.6; DOH notice OHIP-3868 · checked Oct 2026 · Official source · From Health Appeal Map: New York

Key facts for New York

Health Appeal Map

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Deadline to ask for a Medicaid hearing
60 days
Medicaid health plan: appeal to the plan first
60 days (federal rule)

Health Appeal Map: New York · checked Oct 2026

Documents to gather

  • The denial letter and any explanation of benefits (EOB)
  • Your insurance card and plan booklet (summary plan description)
  • The claim file and guidelines you requested from the plan
  • A letter from your doctor supporting the care
  • Copies of your appeal and proof of when you sent it
  • Notes of every call with the plan
  • For Medicaid: the notice with its date and your case number

Where to go

Costs

Internal appeals, Medicaid fair hearings and the federal external review process are free. A state program or a plan's contracted reviewer may charge up to $25 for an external review. Requesting your claim file and plan criteria is free.

Talk to a lawyer if

  • The denied care is urgent or very expensive and the plan upheld the denial
  • Your job-based plan's final denial says you can sue under ERISA
  • Your coverage was cancelled back to its start date (rescission)
  • Medicaid is ending your coverage or a service and you need to keep it during the appeal
  • The plan missed its deadlines or won't give you your claim file

Free help

Many states have a Consumer Assistance Program that helps with health insurance problems, including appeals; find it through CMS (cms.gov/cciio/resources/consumer-assistance-grants) or your state page. For job-based plans, EBSA benefits advisors help for free (1-866-444-3272). For Medicare, your State Health Insurance Assistance Program (SHIP) gives free counseling (shiphelp.org). For Medicaid hearings, free legal aid can help: find it through the Legal Services Corporation (lsc.gov/about-lsc/what-legal-aid/i-need-legal-help) or LawHelp.org (lawhelp.org).

Guides for your state

Guides for every state

Questions

Internal appeal to your plan in New York: what is the rule?

New York law requires plans to give you at least 45 days to file a standard appeal. Federal rules give at least 180 days for most plans. The deadline that applies to you is on your denial notice. (N.Y. Ins. Law 4904(b), (c))

Plan's decision on an internal appeal: what is the rule?

72 hours for urgent care; 30 days for care not yet received; 60 days for care already received (29 CFR 2560.503-1(i))

Ask for external review in New York: what is the rule?

You have 4 months to apply. If your plan offers a second-level internal appeal, you do not have to use it; if you do, the 4 months still run from the first appeal decision. If DFS does not receive your application within 4 months, you cannot get an external appeal. A provider appealing on its own behalf has 60 days. (N.Y. Ins. Law 4910, 4914; DFS, New York State External Appeal)

Medicaid managed care plan appeal: what is the rule?

60 calendar days from the date on the plan's notice (42 CFR 438.402(c)(2)(ii))

Medicaid state fair hearing in New York: what is the rule?

Hearing days: 60 days Hearing days from: The date of the action or notice you disagree with (the notice says "60 days from the date of this notice") (N.Y. Soc. Serv. Law 22(4)(a); 18 NYCRR 358-3.5, 358-3.6; DOH notice OHIP-3868)

Keep Medicaid services during the appeal in New York: what is the rule?

If the agency had to give you advance notice, your Medicaid continues unchanged until the hearing decision (aid continuing) if you ask for a fair hearing before the effective date of the action on your notice. DOH guidance (GIS 25 MA/07) also accepts a request made within 10 days of the mailing of the notice, if that is later. For a notice from NY State of Health, coverage continues if you ask within 10 days of the date of the notice or before the effective date, whichever is later. If you lose, you may have to pay back the cost of benefits you got while waiting. (N.Y. Soc. Serv. Law 22(4)(a); 18 NYCRR 358-3.5, 358-3.6; DOH notice OHIP-3868)

When should I talk to a lawyer?

The denied care is urgent or very expensive and the plan upheld the denial; Your job-based plan's final denial says you can sue under ERISA; Your coverage was cancelled back to its start date (rescission); Medicaid is ending your coverage or a service and you need to keep it during the appeal; The plan missed its deadlines or won't give you your claim file.

How much does it cost?

Internal appeals, Medicaid fair hearings and the federal external review process are free. A state program or a plan's contracted reviewer may charge up to $25 for an external review. Requesting your claim file and plan criteria is free.

Plans by state

Open the plan with one state's rules filled in:

Sources

Plan checked Oct 2026. Independently fact-checked 2026-10-31.

This plan is general legal information, not legal advice. RobinClaim is not a law firm. Laws and deadlines change and have exceptions: check with the official source or a lawyer or legal aid office about your own case. How we research.