NY Manual
SHP Manual

New York Provider Manual
15.14 Member Complaints – Medicaid, FHPlus | 15.16 Appealing the Grievance – Commercial, CHPlus

15.15 Standard Appeals – Commercial, CHPlus

A CHPlus or Commercial member or a member’s designee shall have 45 (forty-five) or 180 days, respectively, from the date an adverse determination notice is received to file a standard appeal. Healthfirst will accept an oral or written standard appeal. An oral appeal can be filed by calling our toll-free Member Services number, Monday to Friday, 8am–8pm.

We will send a notice that the appeal has been received for review within 15 (fifteen) calendar  days of our receiving the request. The appeal will then be investigated and a decision made within 60 (sixty) calendar days for standard CHP appeals.

Appeals for Commercial members are conducted according to the following timelines.  Appeals related to a preauthorization request will be decided within 30 (thirty) calendar days of receipt of the appeal request.  Appeals related to a retrospective appeal will be decided within 60 (sixty) calendar days of receipt of the appeal request.  Expedited appeals will be determined within the earlier of 72 hours of receipt of the appeal or two (2) business days of receipt of the information necessary to conduct the appeal. 

Healthfirst’s failure to render a determination of an appeal within 60 (sixty) calendar days of receipt of the necessary information for a standard appeal or within two (2) business days of receipt of the necessary information for an expedited appeal will be deemed a reversal of the initial adverse determination. 

Once we make a decision for all types of appeals, the member or member’s designee, as appropriate, will be notified within two (2) business days of our reaching a decision. This notice will include the reasons (and any related medical information) for our decision and further appeal rights.

Providers should submit clinical information along with the request for an appeal, and in any event, within 10 calendar days of the request. Clinical documentationcan be faxed to the Appeals and Grievances department, fax # 1-646-313-1618.

Healthfirst will request any clinical documentation required to substantiate services. However, failure to provide requested clinical information in a timely manner may put member’s health in jeopardy.