Access to Care and Service Staying Healthy and Living with Illness Quality of Providers Grievances

Complaints Prompt Pay Complaints Internal Appeals External Appeals

HMO	Total Reviews	Reversed Reviews	Reversed In Part	Upheld Reviews	Reversal Rate1
Aetna Health Inc.	22	7	1	14	36.4%
Atlantis Health Plan	11	5	1	5	54.5%
CDPHP	14	6	1	7	50.0%
Community Blue (HealthNow)	19	5	5	9	52.6%
Empire HealthChoice HMO, Inc.	161	73	8	80	50.3%
Excellus Health Plan, Inc. (HMO)	67	30	2	35	47.8%
GHI HMO Select, Inc.	9	4	0	5	44.4%
Health Net of NY, Inc.	107	38	6	63	41.1%
HIP HMO	83	21	8	54	34.9%
Independent Health Association, Inc. (IHA)	11	8	0	3	72.7%
MVP Health Plan, Inc.	21	9	0	12	42.9%
Oxford Health Plans of NY, Inc.	97	38	4	55	43.3%
Rochester Area HMO, Inc. (Preferred Care)	16	8	1	7	56.3%
Total	638	252	37	349	Avg. = 45.3%

Understanding the Table

When your HMO denies health care services because it claims services are experimental, investigational, not medically necessary or for HMO members, an out-of-network service, you can request an external review in which an outside medical professional reviews your case.

For each HMO, the table tells you:

• Total number of external appeals - Cases submitted to independent external review organizations in 2008.

• Number of reversed appeals - Cases where the independent external review organizations decided in favor of the consumer.

• Number of reversed in part appeals - Cases where an independent external review organization decided partially in favor of the consumer. For example, an HMO may refuse payment of a five-day hospital stay claiming it was not medically necessary. The external review organization may then decide that only three of the five days were medically necessary.

• Number of upheld appeals - Cases where external review organizations agreed with the insurer's decidion not to cover a service or procedure.

• Reversal rate - Percentage of cases in which the external review agent decides that the HMO's decision to deny coverage should be changed. In other words the reversal rate is the percentage of reviews decided in favor of the consumer. Please note that reversed in part decisions are included in the reversal rate.

Keep in mind...

The Independent External Review category is only one of eight performance areas presented.

Before requesting an external review, you must complete the HMO's first level internal utilization review appeal process, or you and your HMO may agree jointly to waive the internal appeal process. For more information on the independent external review process, call the hotline at 1‑800‑400‑8882 or go to the External Review page.

Remember, you have the right to an external review of any final adverse decision denying coverage because the procedure, service or treatment is considered not medically necessary.

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