Health insurance or Medicaid said no in New York? Deadlines and free help

In New York, state-regulated health plans are overseen by New York State Department of Financial Services (DFS) and New York State Department of Health (DOH), Managed Care Complaint Unit.

New York runs its own independent review of denials: New York State External Appeal. You generally have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

New York Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (NY State of Health) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in New York?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
60 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – NY State of Health
60 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

If you bought insurance yourself or get it from an employer who does business only in New York, contact DFS. If your plan is a self-insured employer plan (often a large company or one in several states), contact the U.S. Department of Labor. For problems getting care from a DOH-certified managed care plan, you can also call the DOH Managed Care Complaint Unit.

Step 1: Appeal to your plan in New York

What it is called: Internal appeal (utilization review appeal) with your plan

You can appeal in writing or by phone. The plan must confirm your appeal in writing within 15 days and decide within 30 days after it has the information it needs. An expedited appeal (for example, ongoing treatment, home care after a hospital stay, or when your provider says an immediate appeal is needed) must be decided within 2 business days after the plan has the information it needs. If you ask for an expedited internal appeal, you can ask for an expedited external appeal at the same time.

Law: N.Y. Ins. Law 4904(b), (c)

All the details →

Step 2: Outside review in New York

New York State External Appeal

Deadline to ask: 4 months.

All the details →

Urgent care in New York: faster decisions

Outside review

An external appeal is expedited if your doctor says a delay would pose an imminent or serious threat to your health, or if you got emergency care and are still in the hospital. The decision is made within 72 hours, or within 24 hours for a non-formulary drug. A doctor's expedited attestation form is needed for an expedited medical necessity appeal.

Law: N.Y. Ins. Law 4910, 4914

Standard: 30 days

Medicaid

If a delay would seriously risk your health, life or ability to function, you can ask OTDA for a fast track fair hearing and send information that shows why (you can upload it at upload.ny.gov). In New York City, emergency fair hearings can be requested at 1-800-205-0110. For NY State of Health eligibility appeals, ask in writing with a note from your medical provider (call 1-855-355-5777).

Law: N.Y. Soc. Serv. Law 22(4)(a); N.Y. Soc. Serv. Law 18 NYCRR 358-3.5, 358-3.6; DOH notice OHIP-3868

Marketplace

If a delay would seriously jeopardize your life, health or ability to get back maximum function, ask for a fast-track appeal in writing with a note from your medical provider. A fast-track appeal is decided as soon as possible.

Law: form DOH-5231

Complaints about your plan in New York

For other problems with an insurance company, such as coverage questions or a complaint about an insurer, you can file a complaint with DFS online or call 1-800-342-3736. For problems getting care from a DOH-certified managed care plan (appointments, referrals, quality of care, billing or refusal to pay), call the DOH Managed Care Complaint Unit at 1-800-206-8125 or write to NYS Department of Health, Managed Care Complaint Unit, OHIP DHPCO 1CP-1609, Albany, New York 12237 (email managedcarecomplaint@health.ny.gov). You do not have to complain to your plan first.

www.dfs.ny.gov

Medicaid (New York Medicaid) denials in New York

Who holds the hearing: NYS Office of Temporary and Disability Assistance (OTDA), Office of Administrative Hearings; eligibility notices sent by NY State of Health are heard by the NY State of Health Appeals Unit.

Hearing deadline: 60 days

All the details →

Marketplace decisions in New York

Marketplace

NY State of Health · 1-855-355-5777

Appeal deadline

60 days

The date on the NY State of Health notice you are appealing

How to appeal

Call 1-855-355-5777, or send the Appeal Request Form (DOH-5231) or a letter by uploading it to your NY State of Health account, by fax to 1-855-900-5557, or by mail to NY State of Health Appeal Unit, P.O. Box 11729, Albany, NY 12211. Give your Marketplace Account ID (starts with "AC") and the date of the notice, and say why the decision should change. Customer service may first try to fix the problem in an informal review.

Form

NY State of Health Appeal Request (DOH-5231)

Faster appeal

If a delay would seriously jeopardize your life, health or ability to get back maximum function, ask for a fast-track appeal in writing with a note from your medical provider. A fast-track appeal is decided as soon as possible.

Coverage while you appeal

You can ask to keep your eligibility and coverage while you appeal (check the box in Section 4 of the form or ask when you call). If you lose, you may have to pay for coverage during that time.

If you disagree

Decisions about Qualified Health Plan eligibility, premium tax credits and cost-sharing reductions can be appealed to the federal Marketplace (HHS) within 30 days of the decision date. You can also bring an Article 78 case in New York State court within 4 months of the decision date.

Law: form DOH-5231

Other rights in New York

How fast a plan must decide a prior approval

A plan must decide a request that needs prior approval and tell you and your provider by phone and in writing within 3 business days after it has the information it needs (1 business day for inpatient rehabilitation after a hospital stay).

Law: N.Y. Ins. Law 4903(b)(1)

Step therapy exceptions

If your plan makes you try other drugs first (step therapy), your provider can ask for an override. The plan must grant it within 72 hours of getting supporting information that shows, for example, the required drug is likely to harm you, will not work, already failed, or you are stable on your current drug. If your health is in serious jeopardy without the drug, the decision is due within 24 hours.

Law: N.Y. Ins. Law 4903(c-1), (c-2)

External appeal for a non-formulary drug

An expedited external appeal about a non-formulary drug must be decided within 24 hours; a standard one within 72 hours.

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in New York and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in New York

Good to know in New York

  • New York's external appeal can be used by Medicaid managed care members too, but if you ask for both a fair hearing and an external appeal, the fair hearing decision is final (N.Y. Ins. Law 4910(d)).
  • DFS publishes past external appeal decisions in a searchable External Appeals Database (DFS, New York State External Appeal).
  • New York gives 60 days to ask for a Medicaid fair hearing on a local agency notice, shorter than the federal maximum of 90 days.

    Law: N.Y. Soc. Serv. Law 22(4)(a); 18 NYCRR 358-3.5

Changes in 2024–2026

From January 1, 2027, amendments to N.Y. Ins. Law 4903 and 4904 change the wording "substance use disorder" to "substance-related and addictive disorder" in the rules for inpatient treatment reviews and 24-hour expedited appeals. Under New York's CMS-approved compliance plan, a Social Security Act 1902(e)(14) waiver kept extra Medicaid fair-hearing protections in place through December 31, 2025: services continued at pre-hearing levels pending a decision even without a timely aid-continuing request, and no recovery of their cost for aid continuing granted before December 31, 2025 (DOH, 2025 Fair Hearing Update; GIS 25 MA/07). These protections are not stated to continue in 2026; the regular rules apply.

Law: 18 NYCRR 358-3.6

Questions about appeals in New York

How long do I have to appeal a health insurance denial 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. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in New York?

New York State External Appeal. Apply online through the DFS Portal (choose "DFS Portal Login"), or complete the fillable New York State External Appeal Application and send it by email to earesponse@dfs.ny.gov, by fax to 1-800-332-2729, or by certified or registered mail to the Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210. Attach the patient consent form (actual signature needed) and, for some appeal types, a physician attestation form.

Is outside review free in New York?

Your plan may charge up to $25 per external appeal, but not more than $75 in one plan year. There is no fee if you have Medicaid or Child Health Plus, or if the fee would be a hardship.

How long do I have to ask for a Medicaid fair hearing in New York?

60 days. The date of the action or notice you disagree with

Can I keep my Medicaid benefits while I appeal 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.

How do I appeal a Marketplace decision in New York?

Call 1-855-355-5777, or send the Appeal Request Form (DOH-5231) or a letter by uploading it to your NY State of Health account, by fax to 1-855-900-5557, or by mail to NY State of Health Appeal Unit, P.O. Box 11729, Albany, NY 12211. Give your Marketplace Account ID (starts with "AC") and the date of the notice, and say why the decision should change.

Not about a denied claim?

Nearby states

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