NY Manual
SHP Manual

New York Provider Manual
15.8 Coverage Determinations for Prescription Drugs – Medicaid, FHPlus, CHPlus | 15.10 Action Appeals – Medicaid, FHPlus

15.9 Action Denial Notice – Medicaid/CHPlus

An action can be considered any of the following activities of the Plan or its delegated entities that results in:

·     The denial or limited authorization of a Service Authorization Request, including the type or level of service.
·     The reduction, suspension, or termination of a previously authorized service.
·     The denial, in whole or in part, of payment for a service.
·     Failure to provide services in a timely manner, as defined by applicable state law and regulation.
·     Failure of Healthfirst to act within the time frames for resolution and notification of determinations regarding Complaints, Action Appeals, and Complaint Appeals provided in Section 15.6 of this manual.
·     The restriction of an enrollee to certain network providers under the Contractor’s Recipient Restriction Program.