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 Organizational Determinations and Reconsiderations – Medicare

When Healthfirst receives a request for payment or to provide services to a member, it must make an organizational determination to decide 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 organizational determination from Healthfirst. This member should be referred to  their EOC or contact Healthfirst Member Services for additional information.

Healthfirst is required to make organizational 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 Organizational Determinations & Reconsiderations (Appeals)

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

All appeal requests must be made in writing within sixty (60) calendar days from the date of the notice of organizational determination. Healthfirst may extend the time frame for filing a request for reconsideration for good cause.

A member or a member’s representative may request a standard appeal request of an organizational 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 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

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.