NY Manual
SHP Manual

New York Provider Manual
14.6 Quality Evaluation of Providers | 15.2 SNF/HHA/CORF Provider Service Terminations – Medicare

15. Appeals and Grievances

Please note:

Medicare-related information can be found in Sections 15.1 through 15.7.

Medicaid/CHPlus/Commercial-related information can be found in Sections 15.8 through 15.18. 

 

15.1 Provider Notice Requirements – Medicare

Because Healthfirst serves various types of members who are covered under a variety of commercial and governmental contracts, the requirements for appeals and grievances may differ among the different products offered. The title bar above each section indicates the program(s) for which the information applies. The sections within Appendix XIII contain copies of all forms, notifications, and documents referenced in this section.

Member Dissatisfaction with Specialist Providers

Members who are not satisfied with the care provided by a particular specialist provider have the option of switching to an alternative in-network provider of the same specialty if a suitable alternative exists. The member’s PCP must be involved in the transition of the member to an appropriate specialist and should discuss the issue with the member. The PCP may also suggest that the member obtain a second opinion prior to changing a specialist altogether.

If the PCP feels strongly that the specialist with whom the member is dissatisfied is uniquely qualified to deal with the member’s medical needs, the PCP should discuss this with the member, in an attempt to continue the existing relationship. If the member still wants to change specialists, the PCP should refer the member to a new specialist and inform him/her to contact Member Services to file a grievance against the initial specialist.

Noncovered Benefits

If the provider recommends a course of treatment or service that is a noncovered benefit, the provider must:

·     Inform the member, in writing, that the service or item may not be covered by Healthfirst and that the member will be responsible for payment of those services.
OR
·     If the provider is willing to waive payment, inform the member that he or she will be held harmless for payment if Healthfirst determines that the treatment or service is not covered. Where a provider has not been given a list of covered services by Healthfirst or the provider is uncertain as to whether a service is covered, the provider should make reasonable efforts to contact Healthfirst to obtain a coverage determination prior to advising a member about coverage and liability for payment and prior to providing the service.