NY Manual
SHP Manual

New York Provider Manual
15.15 Standard Appeals – Commercial, CHPlus | 15.17 Expedited Appeals – Commercial, CHPlus

15.16 Appealing the Grievance – CHPlus, Commercial (Small Group)

A member or a member’s designee shall  60 (sixty) business days after receipt of notice of the grievance determination to file an appeal.

Within 15 (fifteen) business days of receipt of the appeal, Healthfirst shall provide written acknowledgment of the 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.

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 grievance determination.

Healthfirst individual market commercial members do not have grievance appeal rights. If a Healthfirst Leaf Plan member is dissatisfied with the grievance determination, they may call the New York State Department of Health at 1-800-206-8125 or write to them at New York State Department of Health, Corning Tower, Empire State Plaza, Albany, NY 12237.

Timeliness of Appeals Determination

Healthfirst shall seek to resolve all appeals of grievances in the most expeditious manner and shall make a determination and provide notice no more than two (2) business days after the receipt of all necessary information when a delay would significantly increase the risk to a member’s health.  Grievance appeals for pre-service grievances will be decided within 15 calendar days of receipt of the appeal.  Post-service grievance appeals will be decided within 30 calendar days of receipt of the appeal.  All other grievance appeals (e.g., for issues not in relation to a claim or request for a service or treatment) will be decided within 30 (thirty) business days after the receipt of all necessary information.

Notice of Appeals Determination

The notice of a determination on an appeal shall include the detailed reasons for the determination, and in cases where the determination has a clinical basis, the clinical rationale for the determination.

Healthfirst shall not retaliate or take any discriminatory action against a member because a member has filed an appeal or grievance.