Overview of the Appeal Process for Denial of Authorization of Treatment for a Certified Health Condition

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The Overview of the Appeal Process for Denial of Authorization of Treatment for a Certified Health Condition provides World Trade Center (WTC) Health Program members with a brief summary of the appeal process; timelines for the appeal process; information about the option to make an oral statement during the appeal review; and Frequently Asked Questions about the appeal process.

If you need help in understanding the appeal process, call:

WTC Health Program Call Center
1.888.982.4748
Monday through Friday
9 a.m. to 5 p.m. (Eastern Time Zone)

The Call Center will refer you to the appeal coordinator who can explain the appeal process and answer any questions you may have.

Brief Summary of the Appeal Process for Denial of Authorization of Treatment for a Certified Health Condition

Members of the WTC Health Program who have been denied authorization of treatment for a certified health condition by the WTC Health Program have the right to appeal the denial decision.

To appeal, you must send a written and signed request to the WTC Health Program within 120 calendar days from the date on the top of the denial letter. The request may be mailed or scanned and transmitted electronically to the Program.

The written request must:

• Identify the member (and designated representative, if applicable) appealing the decision;
• Describe the decision being appealed and state the reason(s) why you believe the decision is incorrect and should be reversed. The appeal request may include scientific or medical information correcting factual errors, information demonstrating that the WTC Health Program did not correctly follow WTC Health Program policies or procedures, any information demonstrating that the WTC Health Program decision was not reasonable, and/or relevant new information not previously considered by the WTC Health Program; and
• Be sent to the WTC Health Program at the address specified in the notice of denial.

The written letter can also include:

• A request to make an oral statement
• A request to designate a representative

After the Program receives a valid appeal, the Administrator will appoint a Federal Official independent of the WTC Health Program to review the case. The Federal Official will review all available records and assess whether the appeal should be granted, as promptly as possible. After the review is completed, the Federal Official’s recommendation on the appeal will be sent to the Administrator.

The Administrator will review the Federal Official’s recommendation and any relevant information and make a final decision on the appeal. The Administrator will notify the WTC Health Program member and/or designated representative in writing of the decision and any administrative actions taken in response to the final decision. If your appeal is denied, no further consideration will be given to your appeal request by the Program and any further action would have to be pursued legally outside the administrative appeal process of the Program.

Making an Oral Statement. You can request the opportunity to make an oral statement to the Federal Official during the appeal review at the time you send your appeal request letter to the appeal coordinator. You can also request to make an oral statement within 14 calendar days of receiving the letter from the appeal coordinator notifying you that your appeal request was accepted. See Frequently Asked Questions for more information about how to make an oral statement to the Federal Official.

Using a Representative. You can designate a person to represent your interests during the appeal process. You can designate a representative by sending a letter to the appeals coordinator. See Frequently Asked Questions for more information about how to designate a representative.

Appeal Process Timeline

Notification of Denial of Authorization of Treatment for a Certified Health Condition
Request an Appeal	No more than 120 calendar days after the date of the denial of authorization of treatment for a certified health condition letter	If you want to appeal a denial of authorization of treatment of a certified health condition, you must mail or submit an electronic copy of a written and signed letter to the WTC Health Program within 120 calendar days from the date of the denial letter.
Notification of Whether Appeal Request is Accepted	After Appeal Request has been Received and Validated	The appeal coordinator will notify you by letter after receiving your appeal request to let you know whether or not your appeal request was accepted for review.
Request to Make an Oral Statement [Optional]	At the time of your request or within 14 Calendar Days After Receiving Appeal Review Acceptance Letter	You can request an opportunity to make an oral statement to the Federal Official in your appeal request letter or within 14 calendar days after receiving a letter notifying you of acceptance of your appeal and providing the name of the Federal Official who will review your appeal.
Oral Statement Scheduled [Optional]	Within 60 Days After Receiving Appeal Review Acceptance Letter	You will have 15 uninterrupted minutes to make your statement. After your statement, the Federal Official may ask you questions for no more than 45 minutes. The maximum commitment of time is 1 hour.
Transcript Review [Optional]	Within 14 Calendar Days of Receiving Transcript of Oral Statement	Within 14 calendar days from the date of the appeal coordinator’s letter accompanying the transcript, you must review and return the transcript of the oral statement with any corrections.
Notification of Outcome of Appeal Review	As Promptly as Possible after Administrator Receives the Federal Official’s Recommendation	After the Federal Official’s review is completed, the Federal Official’s recommendation and any relevant information will be sent to the Administrator. The Administrator will make a final decision on the appeal and notify you of the final decision and any actions resulting from the decision.

Frequently Asked Questions

Several FAQs are provided on our FAQ page on what to do if you disagree with a decision made by the WTC Health Program.