Get - Dfs Ny

This guide provides a clear and supportive approach to filling out the Dfs Ny form for external appeals in New York State. Whether you are a patient or a provider, this resource will walk you through each section of the form step-by-step.

Follow the steps to successfully complete your external appeal application.

1. Click ‘Get Form’ button to access the external appeal application and begin filling it out.
2. In the applicant name section, enter the full name of the person submitting the appeal, whether it's the patient or their designee.
3. Provide the patient’s name in the next section. It is essential that this matches the name associated with the health plan.
4. Complete the patient’s address, including street, city, state, and zip code. Ensure accuracy to avoid any issues with correspondence.
5. Enter the patient’s primary and secondary phone numbers, including the area codes. This is important for communication regarding the appeal.
6. Fill in the patient’s email address. This will be used for any electronic communications from the Department of Financial Services.
7. In the patient health plan section, write the health plan's name and the patient’s ID number as it appears on their health card.
8. Record the name and contact details of the patient’s physician or prescriber, including their address and phone number.
9. If applicable, indicate whether the patient has requested a fair hearing through Medicaid or if they received a determination by checking 'Yes', 'No', or 'Don’t know'.
10. If you are filling out the form as a designee, complete the section for designee information, including their relationship to the patient.
11. Select the reason for the health plan denial from the options provided and attach any required physician’s attestation for expedited appeals.
12. Decide if the appeal should be expedited and check the corresponding box based on the urgency of the case.
13. Complete the section for providers if applicable, attaching necessary documentation regarding the initial denial.
14. Attach any description or dates of the services provided as additional context for the appeal.
15. Indicate external appeal eligibility by checking the appropriate box. Ensure all required final determinations are included.
16. Provide payment details for any external appeal fee, if required by the health plan, along with any checks or money orders.
17. Finally, read through the patient consent section and ensure it is signed and dated appropriately. Double-check all information for accuracy.
18. Once all sections are complete, save your changes. You may download, print, or share the form as needed.

Complete your external appeal application online to ensure a smooth and efficient process.