How to Appeal an Insurance Denial for ADHD Care in New York

A denial letter is the start of a process with fixed deadlines, and in New York that process ends, for most state-regulated plans, with a reviewer who does not work for your insurer. For adult ADHD care the denials that come up most are a medication that needs prior authorization or is off the formulary, neuropsychological testing judged not medically necessary, and a request to see an out-of-network psychiatrist when the network has no one suitable.

This is general information about the process, not legal advice. The agencies named below can advise on your specific case at no charge.

Step 1: Identify the plan type and the reason for denial

Two facts decide your route.

• Who regulates the plan. The Department of Financial Services (DFS) states that its protections apply to policies bought in New York and do not apply to out-of-state policies or self-funded employer coverage. Ask HR whether your plan is fully insured or self-funded. See does insurance cover adult ADHD care in New York.
• Why the claim or request was denied. The letter should state the reason. External appeal covers denials because care is not medically necessary, is experimental or investigational, or is out of network. Other kinds of denial, such as a service the contract excludes, are not on that list, though you can still complain to the insurer and to DFS.

Ask the insurer for the clinical review criteria it used. For mental health decisions, New York-regulated insurers must use State-approved tools and a clinical peer reviewer with relevant specialty experience, and members can request the criteria.

Step 2: File the internal appeal

You have 180 days to appeal to the insurer. Do not wait that long. File in writing, keep a copy, and include:

• the denial letter and claim or reference number;
• a short statement of what you are asking the plan to approve;
• a letter from your prescriber or clinician explaining why the service or drug is needed for you, including what has already been tried;
• relevant records, such as the evaluation report;
• for medication, the exact drug, form and strength, and the reason formulary alternatives are not suitable.

A sample opening:

• I am appealing the denial dated [date], reference [number], of [service or drug]. Please send me the clinical review criteria used in this decision. My clinician's letter of medical necessity and supporting records are enclosed.

The insurer's answer to this appeal is the final adverse determination. Keep the letter and note its date, because the next deadline runs from it.

Step 3: File an external appeal with DFS

If the insurer upholds the denial, an external appeal sends the dispute to an independent external appeal agent. DFS states that the agent's decision is binding on the patient and the health plan.

The second row is the one people miss. Pursuing an optional second-level internal appeal does not pause the external appeal clock.

How to submit

1. Online through the DFS Portal, which DFS lists as the preferred method.
2. By mail to the Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210. Use certified mail so you have proof of the date.
3. By fax or email using the number and address on the current application form.

For help with the application, DFS lists (800) 400-8882. The fax line for expedited appeals is listed as (888) 990-3991. Confirm both on the DFS page before using them.

You will need a signed patient consent to release records. Depending on the type of appeal, a physician attestation is also required:

• Standard medical necessity or standard formulary exception: no attestation is required, though a supporting letter helps.
• Expedited appeal: the physician attests that the standard timeframe would seriously jeopardize your health or ability to function, or you are in a current course of treatment with a non-formulary drug.
• Out-of-network referral: the physician attests that the plan has no in-network provider with the appropriate training and experience to meet your needs.
• Out-of-network service: the physician attests about the alternate in-network service the plan offered and why the requested service differs.

Out-of-network denials: ask before you go

If your goal is to have a plan cover an out-of-network psychiatrist because no in-network clinician can treat you, make the request to the insurer before you receive the service, and get the denial in writing. A DFS consumer guide describes a prior request to the insurer as a condition of an out-of-network external appeal.

For first appointments, a faster route often exists. Under the State's 10-business-day standard, an access complaint to the insurer can lead to an approved out-of-network referral without a formal appeal. See New York's 10-business-day rule. An ordinary reimbursement dispute, where the plan paid less than you expected for out-of-network care you chose, is a different matter, covered in how out-of-network reimbursement works.

If your plan is self-funded, Medicaid or Medicare

• Self-funded employer or union plan. DFS protections do not apply. Follow the appeal steps and deadlines in the denial letter and the Summary Plan Description. For questions about your federal rights, contact the U.S. Department of Labor's Employee Benefits Security Administration at (866) 444-3272. Whether DFS will accept an external appeal for a particular self-funded plan was not confirmed on the DFS page, so ask DFS or the plan.
• Medicaid Managed Care. You can use the plan's appeal process, and the external appeal fee is waived. Complaints about a plan go to the Department of Health at (800) 206-8125.
• Medicare. Medicare has its own federal appeals process. Follow the instructions on the notice you receive.

Who can help for free

Numbers are as printed on State and federal pages in 2025 and 2026. Check the agency's site before you call.

A checklist to keep by the phone

• Date of the denial and the 180-day internal deadline.
• Date of the final adverse determination and the 4-month external deadline.
• Name, date and reference number for every call.
• Copies of everything you send, with proof of delivery.
• Your clinician's letter and the insurer's clinical criteria.

Your prescriber's office is part of most appeals, since the medical necessity letter and any attestation come from the clinician. Ask early what the office needs from you. General information about how this practice handles insurance paperwork is on the fees and insurance page, and you can reach the office through the contact page.