NY Manual
SHP Manual

SHP Provider Manual
3.4 Sample Service Plan Letter (Page 2) | 3.6 Sample Service Plan Update Letter (Page 2)

3.5 Sample Service Plan Update Letter (Page 1)

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Senior Health Partners, Managed Long-Term Care Plan
100 Church Street, New York, NY 10007
TTY/TDD 1-888-542-3821
<<r_first_name>> <<r_last_name>>
<<r_city>> <<r_state>> <<r_zip>>
Enrollee ID: <<m_id>>
Coverage type: <<m_coverage_plan_name>>
Service: [describe requested or claimed service including: amount/duration/date of service]
Provider: <<sp_full_name>>
Plan Reference Number: <<re_authorization_number>>
Dear <<m_full_name>>:
You are getting this notice because your health plan has approved your Outpatient Service.
On <<insert auth request date>> you asked Senior Health Partners, Managed Long-Term Care Plan for the service listed above.
Senior Health Partners Plan has decided this service is [a covered benefit] [medically necessary] [approved to be provided by an out-of-network provider].
[[Provider Name] is a [participating provider.] [an out of network provider. You are not responsible for any extra payments, but you will still have to pay your regular co-pay or co-insurance if you have any].
This approval does not guarantee payment. Payment is based on your active enrollment in Senior Health Partners Plan at the time you received the service.  Your provider may confirm eligibility by contacting  Senior Health Partners Plan at 1-877-737-2693, our automated phone system is available 24 hours a day 7 days a week, live representatives are available Monday to Friday 9:00am-5:00pm or your provider can visit our website at www.healthfirst.org. Coordination of benefits guidelines may also apply.
This review was done for coverage purposes and does not replace the professional opinion of your provider of care. The final decision about treatment belongs to you and your provider.
If you would like to speak to Senior Health Partners Plan about this decision, please call 1-800-633-9717
<<SHP18_39 NYSDOH Approved 02142018>>