NY Manual
SHP Manual

New York Provider Manual
15.10 Action Appeals – Medicaid, FHPlus | 15.12 Member Rights to a Fair Hearing – Medicaid, FHPlus

15.11 Expedited Appeals – Medicaid, Medicaid Advantage Plus, and AbsoluteCare

A Healthfirst member, his or her representative, or a participating provider may request expedited consideration of an appeal if the standard time frame would seriously jeopardize the life or health of the member or the member’s ability to regain maximum function. Expedited appeals are processed within 72 hours. 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. Plans must make reasonable efforts to give prompt oral notice of an extension and written notice within two calendar days.

If the member’s designee makes the request, 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, grievance, or fair hearing but may not request Aid Continuing.

Providers should submit supporting clinical information along with the expedited appeal request, and in any event, within 24 hours of the expedited 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 in a timely manner may put a member’s health in jeopardy.

Notice of an Action Appeal 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.

Medicaid and Medicaid Advantage Plan

Healthfirst will promptly notify by phone, and send written notice to the member, his or her designee, and the provider (where appropriate) within 24 hours of the Action Appeal determination.

AbsoluteCare

Healthfirst will promptly notify by phone, and send written notice to, the member, his or her designee, and the provider (where appropriate) within two (2) calendar days of Action Appeal determination.

Healthfirst shall not retaliate nor take any discriminatory action against a member because a member or a member’s representative has filed an Action Appeal.