Health Republic Insurance of New York
Liquidation Administration Website

Appeal Procedure

This claim was processed according to the terms of your health care plan. We have carefully considered the information provided and applied the terms of the plan that apply to your benefit request. The specific plan provisions related to the service or reason code set forth above is described in detail in your plan document. Clinical reasons that your benefit request was ineligible, either in full or in part, may include, but are not limited to, experimental, investigational, medical necessity or cosmetic reasons. Non-clinical reasons that your benefit request was ineligible, either in full or in part, may include, but are not limited to, benefit limitations, exclusions or non-covered expenses. An explanation that applies the terms to the medical circumstances that led to the decision, as well as any internal rule, guideline, clinical judgment or protocol or copies of any other relevant documents that are needed to initiate an appeal will be provided to you upon request.

If you decide to appeal this Explanation of Benefits/Allowance, your appeal should be submitted within 60 days of the date this Explanation of Benefits/Allowance was mailed via the online portal located at www.healthrepublicny.org or by requesting a paper appeal form and submitting it with supporting papers by mail to:

Health Republic Insurance of New York
Case Administration c/o GCG
P. O. Box 10266
Dublin, OH 43017-5766

You will be notified of the decision following review no later than 60 days after your appeal is received. If your appeal is denied following the review, you may file an objection. All objections must be submitted within 30 days of the mailing of the denial via online portal located at www.healthrepublicny.org or by mail to the address listed above. The Liquidator may direct any such objection to mandatory mediation or seek to settle or otherwise resolve the objection. Any unresolved objections will be referred to a referee or healthcare qualified claims examiner, as applicable, to be appointed by the New York State Supreme Court overseeing Health Republic’s liquidation. The referee or healthcare qualified claims examiner will be authorized to review and report on the validity of the objection or issue a final determination upon consent of the parties.

For further assistance in understanding this notice, please visit www.healthrepublicny.org or call (866) 680-0893.

Please be advised that no claim will be paid until all policy claims against Health Republic are adjudicated pursuant to the Claims adjudication Procedure. Claims will be paid based on available general assets. The amount of payment will depend on the percentage of total assets to total claims in each particular claims class.