Appeals

You or your designated representative may submit a request to appeal the following three types of WTC Health Program decisions:

1. Enrollment denial – includes denial of enrollment in the WTC Health Program or disenrollment.
2. Certification denial – includes denial of certification as a WTC-related health condition, denial of certification of a health condition as medically associated health condition, or decertification of a WTC-related health condition.
3. Treatment denial - includes denial of treatment authorization for a certified health condition based on a finding that the treatment is not medically necessary.

For questions about appeals and the appeal process, call the WTC Health Program Call Center at 1-888-982-4748, Monday through Friday from 9 a.m. to 5 p.m. Eastern. The Call Center will refer you to the appeals coordinator, who can explain the appeal process and answer any questions you may have.

In addition to the requirement for a valid appeal request discussed below, there are some concerns that are outside the scope of the WTC Health Program’s administrative appeal process. To learn more about what kind of issues an appeal may and may not address, download the Scope of Appeals [PDF, 3 pages, 786 KB] .

Appeal Process for Denial of Eligibility for Enrollment or for a Disenrollment Decision

Download [PDF, 4 pages, 725 KB]

The Overview of the Appeal Process for Denial of Eligibility for Enrollment or for a Disenrollment Decision in the World Trade Center (WTC) Health Program provides applicants with a brief summary of the appeal process; timelines for the appeal process; 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 appeals coordinator who can explain the appeal process and answer any questions you may have.

Brief Summary of Appeal Process for Denial of Eligibility for Enrollment or for a Disenrollment Decision

Any applicant denied eligibility for enrollment in or a member disenrolled from the WTC Health Program has the right to appeal the 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 or disenrollment letter. The request may be mailed or scanned and transmitted electronically to the Program.

The written request must:

• Identify the applicant or member (and designated representative, if applicable) appealing the decision;
• Describe the decision being appealed and state the reason(s) why you believe the denial of enrollment or decision for disenrollment is incorrect and should be reversed. The appeal request may include 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 or disenrollment.

The written letter can also include:

• A request to designate a representative

Your appeal letter should be mailed or faxed to:
Appeals Coordinator
WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144
Fax: 1-877-646-5308

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 denied applicant or disenrolled 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 WTC Health Program and any further action would have to be pursued legally outside the administrative appeal process of the Program.

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 For Denial of Health Condition Certification or Decertification of a Health Condition

Download [ PDF, 10 pages, 591 KB]

The Overview of the Appeal Process for Denial of Health Condition Certification or Decertification of a 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 appeals coordinator who can explain the appeal process and answer any questions you may have.

Brief Summary of Appeal Process for Denial of Health Condition Certification or Decertification of a Health Condition

Members of the WTC Health Program who have been denied certification of a health condition have the right to appeal the following four types of decisions:

• Denial of certification of a health condition as a WTC-related health condition;
• Denial of certification of a health condition as a health condition medically associated with a WTC-related health condition;
• Decertification of a WTC-related health condition; or
• Decertification of a health condition medically associated with a WTC-related health condition.

To appeal one of the above decisions, 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 or decertification 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 or disenrollment.

The written letter can also include:

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

Your appeal letter should be mailed or faxed to:
Appeals Coordinator
WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144
Fax: 1-877-646-5308

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 appeals coordinator . You can also request to make an oral statement within 14 calendar days of receiving the letter from the appeals 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

Upon receiving the Notification of Denial of a Health Condition Certification, you have 120 calendar days to request an appeal. The full process is outlined below.

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

Download [PDF, 10 pages, 377 KB]

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 appeals 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

Your appeal letter should be mailed or faxed to:
Appeals Coordinator
WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144
Fax: 1-877-646-5308

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 appeals coordinator . You can also request to make an oral statement within 14 calendar days of receiving the letter from the appeals 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 make an oral statement to the Federal Official.

Appeal Process

Upon receiving the Notification of Denial of Authorization of Treatment for a Certified Health Condition, you have 120 calendar days to request an appeal. The full process is outlined below.

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.