NY Manual
SHP Manual

New York Provider Manual
XIII-A Notice Of Medicare Non-Coverage | XIII-C Standard Description and Instructions for Healthcare Consumers to Request an External Appeal

Appendix XIII-B — Important Information for Healthfirst Medicare Plan Members’ Appeal Rights

Healthfirst Medicare Plan

100 Church Street,

New York, NY 10007

If a member does not agree with a decision made by Healthfirst Medicare Plan, the member or the member’s representative has the right to request a reconsideration. If the member believes that his/her health or ability to function could be seriously harmed by waiting 30 days for a service-related standard appeal, he/she may request an expedited 72-hour appeal. Healthfirst will decide if your request meets the requirements under Medicare guidelines. If not, the appeal will be processed under the standard 30-day appeal process.

To request an expedited 72-hour appeal (does not apply to denials of payment):
Appeals Unit
P.O. Box 5166
New York, NY 10274
100 Church Street
New York, NY 10007

To request a 30-day service-related appeal or a 60-day payment-related appeal:

A member can file a service-related appeal, which will be processed within 30 days, or a payment-related appeal, which will be processed within 60 days. The appeal can be submitted verbally or in writing.  

In addition, the member may also file such appeal with the Department of Health and Human Services or the Railroad Retirement Board if the member is a railroad annuitant. Your request will be transferred to Healthfirst for processing.

Help With Your Appeal

Assistance with an appeal request is available at the New York City Department for the Aging, Health Insurance Information, Counseling and Assistance Program (HIICAP) Helpline at 1-212-442-1382; the Medicare Rights Center at 1-888-466-9050 (1-888-HMO-9050); Elder Care Locator at 1-800-677-1116; or you can contact 1-800-633-4227 (1-800-MEDICARE), 24 hours/7 days. TTY/TDD users should call 1-877-486-2048.

14-Day Extension

An extension up to 14 calendar days is permissible for both 30-day and 72-hour appeals, if the extension of time benefits the member; for example, if the member needs time to provide Healthfirst with additional information or if Healthfirst needs to have additional diagnostic tests completed.

Healthfirst will make a decision on the appeal and notify the member of it within 30 days for a standard appeal or within 72-hours for an expedited appeal from the date it is received. However, if our decision is not fully favorable, we will automatically forward the member appeal request to the Centers for Medicare & Medicaid Services’ contractor, as well as the Center for Health Dispute Resolution (The Center), for an independent review. The Center will notify the member of its decision within the same time frames required of Healthfirst. An extension of up to 14 calendar days is also permitted under certain circumstances.