Denial Letter and Appeal Notification - Health Condition

Appendix AA – Certification Denial Letters and Appeal Notifications

Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX

Certification Denial – Responder and Certified Eligible Survivor

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that your health condition, [NAME OF HEALTH CONDITION], is not eligible for certification as a [World Trade Center (WTC)-related health condition or health condition medically associated with your certified WTC-related health condition] because your 9/11 exposure is not substantially likely to be a significant factor in aggravating, contributing to, or causing your health condition.

This determination is based upon an assessment of your individual exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the terrorist attacks, as well as the type of symptoms for your condition and the time interval for development of your condition.

 

[INSERT TEMPLATE LANGUAGE]

The WTC Health Program only provides treatment benefits (i.e., medication or health care services) for a health condition that has been certified as either WTC-related or medically associated with a certified WTC-related health condition. Monitoring or treatment benefits for any health conditions that have previously been certified by the WTC Health Program will not be affected by this denial.

This determination will become final 120 calendar days from the date of this letter unless you file an appeal.

Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta

Appeal Rights

If you believe the denial of your health condition certification was made in error, you may request to appeal the denial by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

327 Columbia Turnpike

Rensselaer, NY 12144

Fax: 1.404.471.8338

The appeal request letter must be postmarked or faxed within 120 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the denial is incorrect. If you choose to make an oral statement as a part of your appeal and/or you would like to designate an individual to represent you during the appeal process, this information should also be included in your letter. Information about the oral statement and designating a representative can be found in the Overview of the Appeal Process for Denial of Health Condition Certification enclosed with this letter.

Please note that all appeal letters must be signed by you or your representative if you have designated one. Your signature on your appeal request letter indicates that the information provided is correct to the best of your knowledge. Should you have any questions about this letter or the appeal process, please send your questions to [email protected] or call the WTC Health Program at 1-888-982-4748 and ask to speak to the appeal coordinator.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Enclosures:

Overview of the Appeal Process for Denial of Health Condition Certification

Supporting medical information submitted by your WTC Health Program Physician

Certification Denial – Screening Eligible Survivor

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

This letter is to inform you that your health condition, [NAME OF HEALTH CONDITION], is not eligible for certification as a [World Trade Center (WTC)-related health condition or health condition medically associated with your certified WTC-related health condition] because your 9/11 exposure is not substantially likely to be a significant factor in aggravating, contributing to, or causing your health condition.

This determination is based upon an assessment of your individual exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the terrorist attacks, as well as the type of symptoms for your condition and the time interval for development of your condition.

 

[INSERT TEMPLATE LANGUAGE]

As a result, I regret to inform you that you are not eligible for status as a certified-eligible survivor under the requirements specified in Section 3321(a)(2) of Title XXXIII of the Public Health Service Act (the James Zadroga 9/11 Health and Compensation Act of 2010), 42 U.S.C. §§300mm-31. Please note, you remain enrolled in the WTC Health Program as a screening-eligible survivor and do not need to re-apply for enrollment. However, only certified-eligible survivors are eligible for monitoring and treatment by the WTC Health Program. Screening-eligible survivors only receive their initial health evaluation at no cost to them. If you want a second health evaluation in the future, you will be personally responsible for the cost of any additional health evaluations at a WTC Health Program participating medical facility.

This determination will become final 120 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of your health condition certification was made in error, you may request to appeal the denial by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

327 Columbia Turnpike

Rensselaer, NY 12144

Fax: 1.404.471.8338

The appeal request letter must be postmarked or faxed within 120 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the denial is incorrect. If you choose to make an oral statement as a part of your appeal and/or you would like to designate an individual to represent you during the appeal process, this should also be included in your letter. Information about the oral statement and designating a representative can be found in the Overview of the Appeal Process for Denial of Health Condition Certification enclosed with this letter.

Please note that all appeal letters must be signed by you or your representative if you have designated one. Your signature on your appeal request letter indicates that the information provided is correct to the best of your knowledge. Should you have any questions about this letter or the appeal process, please send your questions to [email protected] or call the WTC Health Program at 1-888-982-4748 and ask to speak to the appeal coordinator.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Enclosures:

Overview of the Appeal Process for Denial of Health Condition Certification

Supporting medical information submitted by your WTC Health Program Physician