What is an Action?
Below are considered plan "Actions"
- Senior Whole Health of New York denies or limits services requested by you or your provider; denies a request for a referral;
- decides that a requested service is not a covered benefit;
- reduces, suspends or terminates services that we already authorized;
- denies payment for services;
- doesn't provide timely services;
- doesn't make grievance or appeal determinations within the required timeframes.
Timing of Notice of ActionIf we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we will send you a notice when we make our decision. If we are proposing to reduce, suspend or terminate a service that is authorized, our letter will be sent at least 10 days before we intend to change the service.
Contents of the Notice of ActionAny notice we send to you about an action will:
- Explain the action we have taken or intend to take;
- Cite the reasons for the action, including the clinical rationale, if any;
- Describe your right to file an appeal with us (including whether you may also have a right to the State's external appeal process);
- Describe how to file an internal appeal and the circumstances under which you can request that we speed up (expedite) our review of your internal appeal;
- Describe the availability of the clinical review criteria relied upon in making the decision, if the action involved issues of medical necessity or whether the treatment or service in question was experimental or investigational;
- Describe the information, if any, that must be provided by you and/or your provider in order for us to render a decision on appeal.
How do I File an Appeal of an Action?If you do not agree with an action that we have taken, you may appeal. When you file an appeal, it means that we must look again at the reason for our action to decide if we were correct. You can file an appeal of an action with the plan orally or in writing. When the plan sends you a letter about an action it is taking (like denying or limiting services, or not paying for services), you must file your appeal request within 45 calendar days of the date on our letter notifying you of the action. If you call us to file your request for an appeal, you must send a written request unless you ask for an expedited review.
How do I Contact my Plan to File an Appeal?We can be reached by calling 1-877-353-0185 (TTY/TDD 711) or by writing to Senior Whole Health of New York, 335 Adams Street., Suite 2600, Brooklyn, NY 11201.
The person who receives your appeal will record it, and appropriate staff will oversee the review of the appeal. We will send a letter telling you that we received your appeal, and how we will handle it. Your appeal will be reviewed by knowledgeable clinical staff that was not involved in the plan's initial decision or action that you are appealing.
For Some Actions You May Request to Continue Service During the Appeal Process
If you are appealing a reduction, suspension or termination of services you are currently authorized to receive, within sixty (60) calendar days of the date of the notification of the SWH appeal decision, MLTC members or their authorized representative may request a State Medicaid Fair Hearing by telephone, fax, online or in writing. At the time of the request and at least within ten (10) days of the SWH appeal decision, the member may also ask to continue to receive current authorized services if the member’s appeal involved a reduction, suspension or termination of those current authorized services.
You do not need to specifically request continuation of services in order to obtain the continuation, but you may tell the NY State OTDA that s/he declines the continuation of services. Your services will continue until you:
- withdraw the appeal, or
- the original authorization period for your services has been met, or
- until 10 days after we mail your notice about our appeal decision, if our decision is not in your favor, unless you have requested a New York State Medicaid Fair Hearing with continuation of services. (See Fair Hearing Section below)
Although you may request a continuation of services while your appeal is under review, if your appeal is not decided in your favor, we may require you to pay for these services if they were provided only because you asked to continue to receive them while your appeal was being reviewed.
How Long Will it Take the Plan to Decide My Appeal of an Action?Unless you ask for an expedited review, we will review your appeal of the action taken by us as a standard appeal and send you a written decision as quickly as your health condition requires, but no later than 30 days from the day we receive an appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.) During our review you will have a chance to present your case in person and in writing. You will also have a chance to look at any of your records that are part of the appeal review.
We will send you a notice about the decision we made about your appeal that will identify the decision we made and the date we reached that decision.
If we reverse our decision to deny or limit requested services, or reduce, suspend or terminate services, and services were not furnished while your appeal was pending, we will provide you with the disputed services as quickly as your health condition requires.
In some case you may request an "expedited" appeal. (See Expedited Appeal Process Section below)
Expedited Appeal ProcessIf you or your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the action. We will respond to you with our decision within 2 business days after we receive all necessary information. In no event will the time for issuing our decision be more than 3 business days after we receive your appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.)
If we do not agree with your request to expedite your appeal, we will make our best efforts to contact you in person to let you know that we have denied your request for an expedited appeal and will handle it as a standard appeal. Also, we will send you a written notice of our decision to deny your request for an expedited appeal within 2 days of receiving your request.
If the Plan Denies My Appeal, What Can I Do?If our decision about your appeal is not totally in your favor, the notice you receive will explain: 1) your right to request a Medicaid Fair Hearing from New York State and 2) How to obtain a Fair Hearing, 3) Who can appear at the Fair Hearing on your behalf, and for some appeals, your right to request to receive services while the Hearing is pending, and how to make the request. If we deny your appeal because of issues of medical necessity or because the service in question was experimental or investigational, the notice will also explain how to ask New York State for an "external appeal" of our decision.
State Fair HearingsIf we did not decide the appeal totally in your favor, you may request a Medicaid Fair Hearing from New York State within 60 days of the date we sent you the notice about our decision on your appeal.
If your appeal involved the reduction, suspension or termination of authorized services you are currently receiving, and you have requested a Fair Hearing, you may also request to continue to receive these services while you are waiting for the Fair Hearing decision. You must check the box on the form you submit to request a Fair Hearing to indicate that you want the services at issue to continue. Your request to continue the services must be made within 10 days of the date the appeal decision was sent by us or by the intended effective date of our action to reduce, suspend or terminate your services, whichever occurs later. Your benefits will continue until you withdraw the appeal; the original authorization period for your services ends; or the State Fair Hearing Officer issues a hearing decision that is not in your favor, whichever occurs first.
If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the disputed services promptly, and as soon as your health condition requires. If you received the disputed services while your appeal was pending, we will be responsible for payment for the covered services ordered by the Fair Hearing Officer.
Although you may request to continue services while you are waiting for your Fair Hearing decision, if your Fair Hearing is not decided in your favor, you may be responsible for paying for the services that were the subject of the Fair Hearing.
State External AppealsIf we deny your appeal because we determine the service is not medically necessary or is experimental or investigational, you may ask for an external appeal from New York State. The external appeal is decided by reviewers who do not work for us or New York State. These reviewers are qualified people approved by New York State. You do not have to pay for an external appeal.
When we make a decision to deny an appeal for lack of medical necessity or on the basis that the service is experimental or investigational, we will provide you with information about how to file an external appeal, including a form on which to file the external appeal along with our decision to deny an appeal. If you want an external appeal, you must file the form with the New York State Department of Financial Services within 4 months from the date we denied your appeal.
Your external appeal will be decided within 30 days. More time (up to 5 business days) may be needed if the external appeal reviewer asks for more information. The reviewer will tell you and us of the final decision within two business days after the decision is made.
You can get a faster decision if your doctor can say that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in 72 hours. The reviewer will tell you and us the decision right away by phone or fax. Later, a letter will be sent that tells you the decision.
You may ask for both a Fair Hearing and an external appeal. If you ask for a Fair Hearing and an external appeal, the decision of the Fair Hearing officer will be the one that counts.
Last Updated 02/14/2018
NYS DOH Approved 01/27/2016