NY Manual
SHP Manual

New York Provider Manual
15.9 Action Denial Notice – Medicaid, FHPlus and CHPlus | 15.11 Expedited Appeals – Medicaid, FHPlus

15.10 Action Appeals – Medicaid, and Medicaid Advantage Plus

An Action Appeal is a request for a review of an Action (see Glossary of Terms, Section 18 of Manual). A member or a member’s designee shall have no more than 60 (sixty) calendar days after receipt of the notice of the Action determination for MMC, and 45 (forty-five) calendar days for Medicaid Advantage Plus, to file an appeal, which may be submitted orally by calling Member Services or by submitting a written request.

An oral Action Appeal can be filed by calling the Healthfirst Member Services toll-free telephone during normal business hours, as well as via a telephone system available to take calls during other hours. If the request is made by a member’s designee, the plan may ask for the enrollee´s written consent for representatives to request a plan appeal, grievance, or fair hearing on their behalf. Providers may request an appeal, a grievance, or a fair hearing but may not request Aid Continuing.

Providers should submit supporting clinical information along with the request for appeal, and in any event, within 10 calendar days of the request. Clinical documentation can be faxed to the Appeals and Grievances department, fax # 1-646-313-1618.

Healthfirst will request any clinical documentation required to substantiate services. However, failure to provide requested clinical information within 5 days may put a member’s health in jeopardy.

Within 15 (fifteen) calendar days of receipt of the appeal, Healthfirst shall provide written acknowledgment of the Action Appeal, including the name, address, and telephone number of the individual designated by Healthfirst to respond to the appeal and what additional information, if any, must be provided in order for the organization to render a decision.

Healthfirst shall designate one or more qualified personnel to review the Action Appeal, provided that when the Action Appeal pertains to clinical matters, the personnel shall include licensed, certified, or registered healthcare professionals.

Healthfirst must allow the member or his/her designee, both before and during the Action Appeals process, the opportunity/ability to examine the member’s case file, including medical records and any other documents and records considered during the Action Appeals process. The member may submit evidence and documentation to support their appeal in writing or in person. The member or his/her designee is subject to the Release of Information process.

Initial and Final adverse determinations are compliant with 42CFR438 requirements.

Clinical Matters

The determination of an appeal on a clinical matter is made by personnel qualified to review the appeal, including licensed, certified, or registered healthcare professionals who did not make the initial determination, at least one of whom must be a clinical peer reviewer as defined in Article 49 of the NYS Public Health Law.

Nonclinical Matters

The determination of an appeal on a matter which is not clinical shall be made by qualified personnel at a higher level than the personnel who made the Action determination.

Timeliness of Action Appeals Determination

Healthfirst shall seek to resolve all appeals in the most expeditious manner. Healthfirst must resolve an Action Appeal as fast as the member’s condition requires and no later than 30 (thirty) calendar days from the date of receipt of the Action Appeal.

Healthfirst must resolve Expedited Action Appeals as fast as the member’s condition requires but within 72 hours of the date of the receipt of the Action Appeal.

Time frames for Action Appeal resolution may be extended for up to 14 (fourteen) calendar days if requested by Healthfirst, the member, his or her designee, or the provider if it is in the best interest of the member. We will make reasonable efforts to give prompt oral notice of an extension and written notice within two calendar days.

In the event Healthfirst requires additional information to process the appeal, Healthfirst shall request the additional information in writing.

If Healthfirst does not make a determination within the time frames specified, as applicable, this shall be deemed to be a reversal of the UR agent’s adverse determination.