NY Manual
SHP Manual

New York Provider Manual
15.3 Notification to Members of Non-Coverage of Inpatient Hospital Care – Medicare | 15.6 Expedited Organization Determinations and Appeals – Medicare

15.5 Organization Determinations and Reconsiderations (Appeals)– Medicare

When Healthfirst receives a request for payment or to provide services to a member, it must make an organization determination on whether or not payment and/or coverage is necessary and appropriate. If the determination is not made in a timely manner or is not favorable, the member has the right to request a reconsideration or appeal. A member who disagrees with a practitioner’s decision about a request for a service or a course of treatment has a right to request an organization determination from Healthfirst. The member should be referred to their EOC or should contact Healthfirst Member Services for additional information.

Type of Request
Definitions
Stakeholders Who Can Submit
Member*
(Includes AOR)
Contracted Provider (INN)
Non-Contracted Provider (OON)
Appeal (Pre- Payment)
The review of adverse organization determinations on the healthcare services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the healthcare services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service
Yes
Yes
Yes
Appeal (Post- Payment)
Yes
No
 
Yes
 
Coverage Request (OD/CD)
Request for a decision made by or on behalf of a plan regarding payment or benefits to which an enrollee believes he or she is entitled.
OD = Organization Determination (Part C)
CD = Coverage Determination (Part D)
Yes
Yes
Yes

Healthfirst is required to make organization determinations and process appeals as expeditiously as the member’s health status requires, but no later than indicated in the following chart:

Time Frames for Organization Determinations and Reconsiderations (Appeals)

Organization Determinations
Reconsiderations (Appeals)
Standard – Not to exceed 14 calendar days. (The 14-day deadline may be extended by an additional 14 calendar days if the member requires the extension or Healthfirst justifies the need for additional information that will benefit the member.)
Standard (Service-Related) – Not to exceed 30 calendar days. (The 30-day deadline may be extended by an additional 14 calendar days if the member requires the extension or Healthfirst justifies the need for additional information that will benefit the member.)
Expedited – Not to exceed 72 hours. (The 72-hour deadline may be extended by an additional 14 calendar days if the member requires the extension or Healthfirst justifies the need for additional information that will benefit the member.)
Expedited – Not to exceed 72 hours. (The 72-hour deadline may be extended by an additional 14 calendar days if the member requires the extension or Healthfirst justifies the need for additional information that will benefit the member.)
 
Standard Only – Payment/Claims-Related
Not to exceed 60 calendar days.

A member has a right to appeal if the member believes that:

  • Healthfirst has not paid for emergency, post-stabilization, or urgently needed services

  • Healthfirst has not paid a bill in full  

  • Health services have been furnished by a noncontracting medical provider or facility or supplier that the member believes should have been provided by, arranged for, or reimbursed by Healthfirst

  • Services that the member feels are the responsibility of Healthfirst to provide or pay for have not been received or paid for

  • Previously authorized ongoing course of treatment that has been reduced or prematurely discontinued and member believes the services are still medically necessary  

  • An organization determination has not been made within the appropriate time frames

  • Noncovered services that the member believes should be provided, arranged, or reimbursed have not been provided, arranged, or reimbursed 

Time Frames and Methods for Submitting Standard Appeals

Appeal requests can be made in writing or orally within 60 (sixty ) calendar days from the date of the notice of organization determination. Healthfirst may extend the time frame for filing a request for reconsideration for good cause. Appeals received after the 60-day timeframe must be in writing and state why the request for an appeal was not filed on time.

A member or a member’s representative may also request a standard appeal request of an organization determination in writing or orally. A member can name a relative, friend, advocate, attorney, doctor, or someone else to act on his/her behalf; in some cases, others authorized under state law may act on behalf of the member. Providers and/or member advocate acting on behalf of a member must complete an Appointment of Representative Statement (Appendix XIII-E) for the services in question.

Requests for Additional Medical Documentation

Healthfirst will make reasonable efforts to request clinical documentation to substantiate services in a timely manner in the event the information is not submitted with the initial request. Providers should understand that delays or failures to submit necessary clinical information may put member’s health in jeopardy.

If further information about the member’s appeal is required to render a reconsideration decision, providers must submit the additional information in a timely manner to allow for resolution within regulatory time frames.

For Expedited Reconsiderations:

When participating providers submit requests for expedited considerations of an appeal, they should submit all supporting clinical information with the expedited appeal. If additional information is needed to help resolve the submitted appeal, Healthfirst will make reasonable efforts to contact the provider to request such information.  Any additional Clinical documents should be submitted within 24 hours and can be faxed to the Appeals and Grievances department, fax # 1-646-313-1618.

For Standard Reconsiderations

If additional information is needed to help resolve the submitted  standard appeal, Healthfirst will make reasonable efforts to contact  the provider to request such information.  Any additional informationrequested should be submitted within 10 calendar days and can be faxed to the Appeals and Grievances department, fax # 1-646-313-1618.

Appeal Determinations

If Healthfirst reverses an initial adverse organization determination, then services will be authorized or provided as expeditiously as the member’s health condition requires, but no later than 30 (thirty) calendar days from the date the request for standard appeal was received or no later than upon expiration of an extension; and within 72 hours from the date the request for expedited appeal was received or no later than upon expiration of an extension. For payment-related requests, payment will be made no later than 60 (sixty) calendar days after the appeal request was received.

If Healthfirst upholds an initial adverse organizational determination upon appeal, the case will be referred to the Independent Review Entity (IRE) contracted by CMS for an independent review.

If CMS’ contractor upholds the Healthfirst adverse organization determination, the contractor will notify the member in writing and explain further appeal options that may be available to the member.

If CMS’ contractor reverses the Healthfirst appeal determination for standard service requests, Healthfirst will effectuate the services appealed within 14 (fourteen ) calendar days of receipt of the IRE’s notice, and if the member’s condition does not allow for this, then services will be authorized within 72 hours from the date of the IRE notice. IRE reversals of expedited service request appeals will be authorized or provided within 72 hours of receipt of the IRE notice. Payment requests that are reversed by the IRE will be effectuated within 30 calendar days of receipt of the IRE’s notice.

If Healthfirst does not complete an expedited appeal process within 72 (seventy-two) hours or a standard appeals process within 30 (thirty) calendar days or payment related within 60 (sixty) calendar days, the case will be automatically referred to CMS’ contractor for an independent review.

A member who wishes to submit a verbal request for an expedited appeal should be directed to 1-877-779-2959.

Please Note: Dual-eligible members only

CompleteCare members have both Medicaid and Medicare benefits and have different options when filing an appeal for services covered under the benefit package. For Healthfirst services funded by the state contract, members must follow Medicaid appeal rules. For services funded through the Medicare program, members must follow Medicare appeal rules. For services covered by both Medicaid and Medicare funding, members can follow either Medicaid or Medicare rules. If a member chooses to pursue Medicaid appeal rules to challenge an organizational determination or action, he/she has 60 (sixty) calendar days from the date on the Notice of Denial of Coverage issued by Healthfirst to also pursue a Medicare appeal, regardless of the status of the Medicaid appeal. However, if a member chooses to pursue a Medicare appeal, he or she may not file an appeal under Medicaid. Healthfirst determines whether Medicaid, Medicare, or both cover a particular service.

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