Overview of the Appeal Process for Denial of Eligibility For Enrollment or for a Disenrollment Decision

Download this page as a PDF

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 appeal 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

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.

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.