Overview Appeal Enclosure June 24 2013 (2)

Overview of the Appeal Process
For Denial of Health Condition Certification

The Overview of the Appeal Process for Denial of Health Condition Certification 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, you can call the WTC Health Program Call Center at 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.
Questions? Contact the WTC Health Program at 1-888-982-4748 or at [email protected]

Brief Summary of Appeal Process for Denial of Health Condition Certification
Members of the WTC Health Program denied certification of a health condition have the right to appeal
the denial of certification, including denial of authorization for treatment of a certified health condition.
To appeal, you must mail or fax a written letter to the WTC Health Program’s appeal coordinator within
60 calendar days from the date on the top of the denial letter. Within 14 days of receiving an appeal
request, the appeal coordinator will notify you by letter if your appeal request is accepted or not. If your
appeal request is accepted, this same letter will provide with the name of the Federal official who will
review your appeal. If your appeal letter is not accepted, you will be informed of the reasons why it was
not accepted. No further consideration will be given to your appeal request.
All accepted appeal requests will be reviewed promptly by the Federal official. If the appeal review is
going to take longer than 60 calendar days from the date of the letter notifying you that your appeal
request is accepted, the appeal coordinator will send a letter to you providing a written explanation of
the delay and the estimated date the review is expected to be completed. After the review is completed,
the appeal coordinator will send you a letter informing you of the Federal official’s final decision on the
appeal and any actions taken by the WTC Health Program resulting from the Federal official’s 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.

Notification of Denial
of Health Condition
Certification

Request an Appeal

No more than 60 calendar
days after the date of the
denial of health condition
certification letter

If you want to appeal a denial of health condition
certification, you must mail or fax a written letter
to the appeal coordinator within 60 calendar days
from the date of the denial letter.

Notification of Appeal
Request Accepted or
Not

Within 14 calendar days
after requesting an appeal

The appeal coordinator will notify you by letter
within 14 calendar days of receiving your appeal
request whether your appeal request was accepted
for review or not accepted for review.

Request to Make an
Oral Statement
[Optional]

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 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 making 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

After review of the transcript of the oral statement,
return the transcript with corrections within 14
calendar days from the date of the appeal
coordinator’s letter accompanying the transcript.

Notification of
Outcome of Appeal
Review

Within 60 Calendar Days
After Receiving Appeal
Review Acceptance Letter

If the appeal review is going to take longer than 60
calendar days from the date of the letter notifying
you that your appeal request was accepted, the
appeal coordinator will send you a letter and
provide you with a written explanation of the delay
and an estimated date the review is expected to be
completed.

Frequently Asked Questions About the
Appeal Process for Denial of Health Condition Certification
Appeal Request
1. Who may request an appeal?
2. When can I request an appeal?
3. How do I request an appeal?
4. What is required to be included in my appeal request letter?
5. What else can I include in my appeal request letter?
6. Are there any limitations on what I can include in my appeal request letter?
7. What happens when my request is received?
8. If my appeal request is accepted for review, what happens next?
9. What happens if my appeal request is not accepted for review?

Appeal Review
10. How will the Federal official review my appeal?
11. How long will it take for my appeal to be reviewed?
12. How will I be informed of the final decision on my appeal?
13. What happens if my appeal is denied by the Federal official?

Using a Representative
14. Can I designate someone to represent me during the appeal process?
15. When can I designate a representative for my appeal?
16. How do I designate a representative for my appeal?
17. How will my representative be recognized by the WTC Health Program?
18. Can I have more than one designated representative at a time?
19. Who is my representative if I am less than 18 years old?

Making an Oral Statement
20. Can I make an oral statement during my appeal?
21. When and how can I request to make an oral statement during my appeal?
22. How will my oral statement be scheduled?
23. What can I say to the Federal official during my oral statement?
24. How do I make my oral statement?
25. Can I make an oral statement in a language other than English?
26. Will the Federal official decide my appeal when I finish my oral statement?
27. What happens if I am unable to make my oral statement at the scheduled date and time?
28. Will there be a transcript of my oral statement to the Federal official for me to review?
29. Can I correct any errors I find in the transcript?

Getting Help
30. Where can I get help if I have questions about the appeal process?

Appeal Request

1. Who may request an appeal?
Enrolled WTC responders or survivors denied certification of a health condition1 may request an appeal.
The term “WTC responder” refers to individuals who responded to the September 11, 2001, terrorist
attacks in New York City, at the Pentagon, and in Shanksville, Pennsylvania. WTC responder also includes
family members of a Fire Department of New York City (FDNY) responder who was killed on September
11, 2001. The term “WTC survivor” may include a screening-eligible survivor, where they are denied
certification of a health condition as a WTC-Related Health Condition, and therefore also denied status as
a certified-eligible survivor; or a certified-eligible survivor denied certification of a second health condition
as a WTC-Related Health Condition.

2. When can I request an appeal?
If you are denied health condition certification, you will receive a letter from the WTC Health Program
notifying you of the denial. You have 60 calendar days from the date on the top of the denial letter to
appeal the denial decision. Note that 60 calendar days is not counted from the postmarked date or
from the date you receive the letter. The 60 calendar days is counted from the date on the top of the
denial letter.

3. How do I request an appeal?
You must mail or fax a written letter to the WTC Health Program’s appeal coordinator. The request must
be postmarked or received by fax within 60 calendar days of the date of the denial letter. If your appeal
request is not postmarked or received by fax within 60 calendar days of the date of the denial letter,
your request will not be considered further. Use the following mailing address or fax number to send
your request to the appeal coordinator:
Appeal Coordinator
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144
Fax: 1.877.646.5308

4. What is required to be included in my appeal request letter?
The following information is required to be included in an appeal request letter: (1) the name, address,
and contact information of the individual who is requesting the appeal; and (2) a clear statement of the
reason(s) why you think the denial was wrong. For example, you can state that the denial was based on
factually inaccurate information, the Program’s policies and procedures were not applied correctly to
the facts of your case, or the denial was not reasonable as applied to the facts of your case. If needed,
contact your Clinical Center of Excellence for information and assistance.

1

Denial of health condition certification also includes the denial of authorization for treatment of a certified health
condition.

5. What else can I include in my appeal request letter?
Request An Oral Statement. If you wish to make an oral statement to the Federal official who will
review your appeal, you may ask for an opportunity to do so in writing in your appeal request letter (see
Making an Oral Statement).
Designate A Representative. If you wish to designate a representative to act on your behalf, you may
include your request in your appeal request letter (see Using a Representative).

6. Are there any limitations on what I can include in my appeal request letter?
An appeal request that objects to the rationale or methodology upon which the WTC Health Program’s
policies and procedures are based is considered to be outside the scope of the Program’s administrative
appeal process.

7. What happens when my appeal request is received?
When your letter or fax requesting an appeal is received by the WTC Health Program, the appeal
coordinator will examine your appeal request to ensure that it meets all of the requirements (see
Appeal Request).

8. If my appeal request is accepted for review, what happens next?
If your appeal request is accepted, the appeal coordinator will notify you by letter within 14 days of
receiving your appeal request. If your appeal request is accepted, the letter from the appeal coordinator
will also inform you of the name of the Federal official who will review your appeal.

9. What happens if my appeal request is not accepted for review?
If your appeal request is not accepted, the appeal coordinator will notify you by letter within 14 days of
receiving your appeal request. The appeal coordinator will inform you of the specific reason(s) why your
appeal request was not accepted. No further consideration will be given to your appeal request by the
WTC Health Program. Further consideration of your appeal request would have to be pursued outside
the administrative appeal process of the WTC Health Program.

Appeal Review
10. How will the Federal official review my appeal?
The Federal official will review any information relevant to denial of status as a certified-eligible survivor
or denial of a health condition certification available in your WTC Health Program member file and
medical record, the information you provided with your appeal request as well as information presented
in your oral statement, if you choose to make one.

11. How long will it take for my appeal to be reviewed?
Appeals will be reviewed promptly. In the rare case that the appeal review is going to take longer than
60 calendar days from the date of the letter notifying you that your appeal request was accepted and
providing you the name of the Federal official reviewing your appeal, the appeal coordinator will send
you a letter providing a written explanation for the delay and an estimated date the review is expected
to be completed.

12. How will I be informed of the final decision on my appeal?
The appeal coordinator will send you a letter with a copy of the Federal official’s final decision on the
appeal and any actions taken by the WTC Health Program resulting from the Federal official’s decision.
For example, if your appeal of the health condition certification denial is granted, these actions could
include certifying a health condition as a WTC-Related Health Condition or recognizing status as a
certified-eligible survivor.

13. What happens if my appeal is denied by the Federal official?
If your appeal is denied, no further consideration will be given to your appeal request by the WTC Health
Program. Further consideration of your appeal request would have to be pursued legally outside the
administrative appeal process of the WTC Health Program.

Using a Representative
14. Can I designate someone to represent me during the appeal process?
Yes. You can designate a representative to act on your behalf in the WTC Health Program, including
representing your interests during the appeal process. Your designated representative can mail or fax a
request for an appeal on your behalf and represent you during the appeal process.

15. When can I designate a representative for my appeal?
You can designate a representative anytime, including anytime during the appeal process.

16. How do I designate a representative for my appeal?
You can designate a representative by sending a letter to the appeal coordinator. In your letter, include
the name, address, and contact information for the individual you designate as your representative.
Mail or fax a letter to the appeal coordinator at the following address or fax number:
Appeal Coordinator
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144
Fax: 1.877.646.5308

17. How will my representative be recognized by the WTC Health Program?
The WTC Health Program will review your designation to ensure that the individual’s service does not
violate any applicable laws. The appeal coordinator will send you a letter notifying you whether or not
your designated representative can be recognized by the Program. If you designate a representative for
the appeal process, and that representative is recognized by the Program, then all communications sent
to you concerning the appeal process will also be sent to your representative.

18. Can I have more than one designated representative at a time?
No. You may only have one designated representative at a time.

19. Who is my representative if I am less than 18 years old?
If you are a family member of a Fire Department of New York City (FDNY) responder killed on September
11, 2001, or a screening-eligible or certified-eligible survivor, and are a minor (less than 18 years of age
in most states), your parent or guardian may act on your behalf. If a parent or guardian will act on
behalf of a minor, mail or fax a letter notifying the Program of the name, address, and contact
information of the person who will act for the minor to the following address or fax number:
Appeal Coordinator
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144
Fax: 1.877.646.5308

Making an Oral Statement
20. Can I make an oral statement during my appeal?
Yes. You can request an opportunity to make an oral statement to the Federal official by telephone
during the appeal review.

21. When and how can I request to make an oral statement during my appeal?
You can request the opportunity to make an oral statement during the appeal review at the time you
send your appeal request letter to the appeal coordinator. Or, you can request to make an oral
statement within 14 calendar days of receiving the letter from the appeal coordinator accepting your
appeal for review and notifying you of the name of the Federal official who will review your appeal. Mail
or fax your letter to the following address or fax number:
Appeal Coordinator
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144
Fax: 1.877.646.5308

22. How will my oral statement be scheduled?
Following the WTC Health Program’s receipt of your request to make an oral statement, the appeal
coordinator will contact you by telephone to discuss and set a convenient date and time for you to make
an oral statement to the Federal official. After three unsuccessful attempts by the appeal coordinator to
contact you, the appeal coordinator will send you a letter explaining that the coordinator has not been
able to contact you to schedule the oral statement and that your review will occur without your oral
statement. The oral statement with the Federal official will be allowed by telephone conference only. If
you want to allow a representative to make an oral statement in your place, you must designate the
representative prior to the scheduling of the oral statement with the Federal official (see Using a
Representative).

23. What can I say to the Federal official during my oral statement?
You can make an oral statement to the Federal official about the reason(s) why you think the denial was
wrong. For example, you can explain why you think the denial was based on factually inaccurate
information, why you think that the Program’s policies and procedures were not applied correctly to the
facts of your case, or why you think the denial was not reasonable given the facts of your case.

24. How do I make my oral statement?
You and/or your designated representative will have a total of 15 uninterrupted minutes to make an
oral statement to the Federal official by telephone. You can share the 15 minutes with your
representative, or you or your representative can use the entire 15 minutes. After you make your
statement, the Federal official may engage you and/or your representative in questions, but for no
longer than 45 additional minutes. The maximum commitment of time for the oral statement, including
questions from the Federal official, is 1 hour.

25. Can I make an oral statement in a language other than English?
Yes. Inform the appeal coordinator at the time you make your request to make an oral statement that
you wish to request translation services for your oral statement. The WTC Health Program will provide
translation services to you at no cost. Family members may not serve as translators.

26. Will the Federal official decide my appeal when I finish my oral statement?
No. The Federal official will review all the information provided during the appeal, including your oral
statement, and you will receive a final decision on your appeal in writing at a later time.

27. What happens if I am unable to make my oral statement at the scheduled date and time?
A second opportunity to make an oral statement to the Federal official will be provided only if you can
show that a medical emergency (or similarly serious situation) prevented you or your designated
representative from being available when the oral statement was originally scheduled.

28. Will there be a transcript of my oral statement to the Federal official for me to review?
Yes. A written transcript of the oral statement (including any questions asked by the Federal official and
responses provided to those questions) will be prepared and provided to you as soon as feasible
following completion of your oral statement.

29. Can I correct any errors I find in the transcript?
Yes. You can correct any errors you find in the transcript. Mail or fax the corrected transcript to the
following address or fax number:
Appeal Coordinator
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144
Fax: 1.877.646.5308

The transcript containing your corrections must be postmarked or received by fax within 14 calendar
days of the date of the appeal coordinator’s letter accompanying the transcript. The corrected transcript
will be provided to the Federal official reviewing your appeal.

Getting Help
30. Where can I get help if I have questions about the appeal process?
If you need help in understanding the appeal process, you can call the WTC Health Program Call Center
at 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.

Questions? Contact the WTC Health Program at 1-888-982-4748 or at [email protected]