NY Manual
SHP Manual

New York Provider Manual
15.11 Expedited Appeals – Medicaid, FHPlus | 15.13 External Review – Medicaid, FHPlus

15.12 Member Rights to a Fair Hearing – Medicaid, Medicaid Advantage Plus

Medicaid and Medicaid Advantage Plus members may request a Fair Hearing regarding adverse determinations concerning:

·     Enrollment, disenrollment, eligibility
·     Denial, termination, suspension, or reduction of a clinical treatment or other benefit package services by Healthfirst that is covered under the Medicaid benefit
·     Healthfirst’s lack of reasonable promptness to act regarding these services

The Medical Management department  will issue the Managed Care Action Taken Form, which contains the member’s Fair Hearing Rights with instructions on how to request a Fair Hearing, along with its initial adverse determination when Healthfirst has denied a request to approve a benefit package service ordered by a participating provider. For Medicaid Advantage Plus members, the Appeals and Grievances department will issue the Managed Care Action Taken Form with the final adverse determination on an Action Appeal of the denial of Medicaid-only services. If you have questions about the Fair Hearing process or would like additional information, please call 1-888-801-1660.