NY Manual
SHP Manual

SHP Provider Manual
6.1 Complaints and Grievances | 6.3 Compliments

6.2 Appeals

   •   An appeal can be written or verbal.

   •   An appeal can be filed by the member, family/caregiver, friend or provider on behalf of the member.

   •   The appeal must be filed within 45 days of the postmarked date of the letter notifying the member of the action

   •   Appeals can be Standard or Expedited

   •   Appeals are tracked by a formal mechanism.

   •   Appeal decisions are made within required time frames, based on the urgency of the issue.

   •   Appeal determinations are made by someone other than the person making the initial determination.

   •   The appeal determination notice includes an explanation of the reasons for the decision, including the clinical rationale and information regarding filing external appeal or Fair Hearing information as appropriate.

   •   A report of appeals is submitted to the Department of Health on a quarterly basis.