Coverage Decisions

A coverage decision is a decision Healthfirst® makes about your benefits and coverage or about the amount we will pay for your medical, behavioral health, and long term care services. We and/or your provider make a coverage decision for you whenever you see your provider. You can also contact your Interdisciplinary Team (IDT) and Care Manager to ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

If you wish to request a coverage decision for medical, behavioral health, and long term care services, please contact Healthfirst AbsoluteCare FIDA Plan:

Call: 1-855-675-7630
TDD/TTY: 711
7 Days a week, 8:00am -8:00pm
Fax: 1-646-313-4603

Write:
Healthfirst AbsoluteCare FIDA Plan
FIDA Care Management
P.O. Box 5165
New York, NY 10274-5165

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 3 business days of receiving your request. However, there are exceptions. For example, for a coverage decisions on a service or item that you already received, we can take up to 14 calendar days. For additional information regarding asking for a coverage decision, see Chapter 9, Section 5.2 of your Participant Handbook. If we decide to take extra days to make the decision, we will tell you in writing. Your IDT or Care Manager will also notify you by phone.

If you believe we should not take extra days, you can file a “fast coverage decision.”

If your health requires it, ask us to give you a “fast coverage decision.”

A fast coverage decision means we will answer within 24 hours. However, we can take up to 3 days if we find that some information is missing that may benefit you or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing and your Care Manger or IDT will notify by phone.

To get a fast decision, you must meet two requirements:

Appeals

An appeal is a request to review the organization determination we made. For example, you can file an appeal if we did not pay for emergency or urgently needed care or if we discontinued a service or type of care you think you need.

Appeals can be standard or fast. A response to a standard appeal can take up to 30 days. If you believe your health or your ability to function could be hurt by waiting for a standard appeal, you may request a fast appeal. We will make a decision on a fast appeal within 72 hours after we receive your appeal.

If you wish to appeal a coverage decision for medical care, please contact Healthfirst AbsoluteCare FIDA Plan:

FIDA Participant Services – Standard Appeal
Call: 1-855-675-7630
TDD/TTY: 711
7 days a week, 8:00am – 8:00pm

FIDA Participant Services – Fast Appeal
Call: 1-877-779-2959
TDD/TTY: 711
7 days a week, 8:00am – 8:00pm
Fax: 1-646-313-4618

Write:
Healthfirst AbsoluteCare FIDA Plan
FIDA Participant Services – Appeals and Grievances
P.O. Box 5166
New York, NY 10274-5166

When we receive an appeal, we review the coverage decision we made to check if we were following all of the rules properly. When we have completed the review, we give our decision.

If we say no to all or part of your Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. Level 2 Appeal is done by the Integrated Administrative Hearing Office (IAHO). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. You may find more information about the Level 2 Appeal process in Chapter 9, Section 5.4 of the Participant Handbook.

Grievances

A grievance is a “complaint” about any problem you have with Healthfirst AbsoluteCare FIDA or our providers. It does not pertain to payment or approval of plan benefits, which are called coverage decisions.

For example, you may complain about how long it takes to make an appointment or about the cleanliness of a provider’s office or you are unhappy with the quality of care, such as the care you received in the hospital.

Call: 1-855-675-7630
TDD/TTY: 711
7 days a week, 8:00am – 8:00pm

Write:
Healthfirst AbsoluteCare FIDA Plan
FIDA Participant Services – Appeals and Grievances
P.O. Box 5166
New York, NY 10274-5166

If you have a complaint, contact us promptly. You have 60 days after the date of the event or incident to make your complaint.

Usually, calling Participant Services at the number shown above is the first step. If there is anything else you need to do, Participant Services will let you know. If you do not wish to call or if you called but were not satisfied with the response, you can put your complaint in writing and mail it to us.

We will answer your complaint either in writing or by telephone (or both) no more than 30 days after the day we receive your letter. If you ask us to, or if we need more than 30 days to respond to your complaint, we may take another 14 days to answer.

Your complaint may be about the amount of time we take to make a coverage decision. For example, if we extend the time frame for reaching a coverage decision, we will respond to your complaint within 24 hours. If you are making a complaint because we denied your request for a fast coverage decision or a fast appeal, we will respond to your complaint within 24 hours.

Who May Ask for a Grievance or an Appeal

You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please either fill out the Appointment of Representative form or send your request in writing. You can fax your form or request to 1-212-801-3250. You can call us at 1-855-675-7630 (TTY/TDD 711) if you need help filling out the form or want to learn more about appointing a representative.

> Appointment of Representative form (English / Español / 中文)

The Appointment of Representative form is also available by visiting the CMS website.

*Please note that clicking on this link will take you away from the Healthfirst website.

Who May Ask for a Coverage Decision

You or someone you name to act for you (your appointed representative) may request a coverage decision. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please either fill out the Appointment of Representative form or send your request in writing. You can fax your form or request to 1-212-801-3250. You can call us at: 1-855-675-7630 (TTY/TDD 711) if you need help filling out the form or want to learn more about appointing a representative.

> Appointment of Representative form (English / Español / 中文)

The Appointment of Representative form is also available by visiting the CMS website.

*Please note that clicking on this link will take you away from the Healthfirst website.

If you need to know about the number of grievances, appeals, and exceptions filed with us, you can contact us at 1-855-675-7630 (TTY 711), 7 days a week, 8:00am to 8:00pm.

Out-of-Network Medical Coverage

With limited exceptions, while you are a Participant of our plan, you must use network providers to get your medical care and services. The only exceptions are: emergencies; urgently needed care when the network is not available (generally, when you are out of the area); out-of-area dialysis services; during transition period that will last for 90 days until your Person-Centered Service Plan is finalized and implemented, whichever is later; when accessing additional benefits and services covered exclusively by Medicaid using your New York State-issued Medicaid identification card ; and cases in which Healthfirst AbsoluteCare FIDA Plan authorizes use of out-of-network providers.

Where to Get More Information and Help

You can get help from the Independent Consumer Advocacy Network (ICAN) if you need more information and to help you understand what to do regarding coverage decisions, appeals and grievances. ICAN is not connected with Healthfirst AbsoluteCare FIDA Plan or with any Medicare Plan. ICAN can help you understand your rights and help you in communicating your concerns. You may contact ICAN at 1-844-614-8800, (TTY 711), Monday – Friday, 8:00am to 8:00pm. The services are free. You can also get help from the New York State Health Insurance Assistance Program (SHIP) which is called Health Insurance Information, Counseling, and Assistance Program (HIICAP). The HIICAP is not connected with Healthfirst AbsoluteCare FIDA Plan or with any Medicare Plan. The HIICAP phone number is 1-800-701-0501. The website is http://www.aging.ny.gov/healthbenefits.

You can also call Medicare directly for help with problems. You may call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY user should call 1-877-486-2048. You may visit the Medicare website at http://www.medicare.gov.