Medicare & Long-Term Care Coverage Decisions, Appeals, and Complaints for Medicare Plan Members

We’re here to help you navigate your Healthfirst Medicare Advantage plan benefits. See below for more information on how you, your doctor, or your appointed representative can call or write us to discuss your coverage concerns.

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If your benefit isn’t covered Healthfirst clinical coverage criteria Appeals Appoint a representative Submit a complaint or grievance

If your benefit isn’t covered

Coverage determinations

A determination is a decision Healthfirst makes about your benefits, coverage, or the amount we will pay for medical service or prescription drugs. A prescription drug determination may be requested when a drug you take is not on the formulary, or you wish to use a drug in a way that is not covered. You, your appointed representative, or your doctor may submit this request. This may result in a coverage exception, or your doctor may decide on an alternate course of treatment.

You, your doctor, or your appointed representative can call or write us to explain the situation.

Call 1-888-394-4327
TTY 711
Monday to Friday, 8:30am–5:30pm
Fax: 1-646-313-4603

Healthfirst Medicare Plan
Provider Services Intake Department
P.O. Box 5166
New York, NY 10274-5166

Next step

We’ll get back to you within 14 days.*

*We’ll reach out if more time is required. If waiting puts your health at risk, you can get a fast decision within 72 hours. If your request is denied, you may submit an appeal. Please see the following section for instructions.

Fill out this form

Please include a statement of support from your doctor with your request.

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Submit to us via fax or mail:

Fax: 1-855-633-7673

CVS Caremark Part D Services
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

Next step

You’ll hear back from us within 72 hours.* If your request is denied, you may submit an appeal. Please see the following section for instructions.

*We’ll reach out if more time is required. If waiting puts your health at risk, you can receive a fast decision within 24 hours.

Need your prescription now?

You may be able to receive a 30-day limited supply of medications to avoid disruption in your care.

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Questions?

Signature (HMO) call: 1-855-771-1081
Signature (PPO) call: 1-833-350-2910
All other Medicare Plans call: 1-888-260-1010
TTY: 1-888-542-3821
Fax: 1-646-313-4618

7 days a week, 8am–8pm (October to March)

Monday to Friday, 8am–8pm (April to September)

Healthfirst clinical coverage criteria

Healthfirst has created publicly accessible internal coverage criteria when coverage criteria are not fully established under the Medicare statute, regulation, national coverage determinations (NCD), or local coverage determinations (LCD). Our internal coverage criteria are based on current evidence in widely used treatment guidelines or clinical literature and comply with CMS requirements. You can view these criteria here:

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Appeals

If you’re dissatisfied with our decision, you, your appointed representative, or your doctor may submit an appeal for us to reconsider the decision. The appeal must be submitted within 65 days of the date on the determination notice.

You, your doctor, or your appointed representative can call or write us to explain the situation.

Signature (HMO) call: 1-855-771-1081
Signature (PPO) call: 1-833-350-2910
All other Medicare Plans call: 1-888-260-1010
TTY: 1-888-542-3821
Fax: 1-646-313-4618

Healthfirst Medicare Plan
Appeals and Grievances
P.O. Box 5166
New York, NY 10274-5166

7 days a week, 8am–8pm (October to March)

Monday to Friday, 8am–8pm (April to September)

Next step

We’ll get back to you within 30 days.*

*We’ll reach out if more time is required. If waiting puts your health at risk, you can get a fast decision within 72 hours. For fast (expedited) appeals, please call 1-877-779-2959 (TTY 711), Monday to Sunday, 8am–8pm, or send a fax to 1-646-313-4618.

Fill out this form

Please include a statement of support from your doctor with your request.

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Submit to us via fax or mail:

Fax: 1-855-633-7673

CVS Caremark Part D Services
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

Next step

You’ll hear back from us with 72 hours.* If your request is denied, you may submit an appeal. Please see the following section for instructions.

*We’ll reach out if more time is required. If waiting puts your health at risk, you can receive a fast decision within 24 hours.

Questions?

Signature (HMO) call: 1-855-771-1081
Signature (PPO) call: 1-833-350-2910
All other Medicare Plans call: 1-888-260-1010
TTY: 1-888-542-3821
Fax: 1-646-313-4618

7 days a week, 8am–8pm (October to March)

Monday to Friday, 8am–8pm (April to September)

Appoint a representative

Fill out a form to appoint a representative to speak and submit complaints and appeals on your behalf. Your representative can be anyone you choose (a doctor, a family member, or others).

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This form is also available on the CMS website
Appointment of Representative form - English Appointment of Representative form - Español

Submit a complaint or grievance

Complaints, also known as grievances, can be about any problem you have with your Healthfirst Medicare Plan or one of our providers. It does not pertain to the payment of or approval of benefits or prescription drugs, which are called determinations (see section on medical and prescription determinations).

Call or write us to explain the situation.

Contact us within 65 days of the incident.

Signature (HMO) call: 1-855-771-1081
Signature (PPO) call: 1-833-350-2910
All other Medicare Plans call: 1-888-260-1010
TTY: 1-888-542-3821
Fax: 1-646-313-4618

Healthfirst Medicare Plan
Appeals and Grievances
P.O. Box 5166
New York, NY 10274-5166

7 days a week, 8am–8pm (October to March)

Monday to Friday, 8am–8pm (April to September)

Next step

Most complaints can be handled by phone. Written complaints will be responded to within 30 days of receipt.*

*If the complaint is due to a denial for a fast (expedited) coverage determination or appeal, the complaint will be responded to within 24 hours.

Call or write us to explain the situation.

Contact us within 60 days of the incident.

Signature (HMO) call: 1-855-771-1081
Signature (PPO) call: 1-833-350-2910
All other Medicare Plans call: 1-888-260-1010
TTY: 1-888-542-3821
Fax: 1-646-313-4618

CVS Caremark Part D
Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330

7 days a week, 8am–8pm (October to March)

Monday to Friday, 8am–8pm (April to September)

Next step

Complaints will be acknowledged immediately in writing once the Appeals and Grievances department has completed their investigation.

If you’re concerned about the quality of care you’ve received, you may also file a complaint with Island Peer Review Organization (IPRO), the State’s Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals who monitor the quality of care given to Medicare beneficiaries.

*If the complaint is due to a denial for a fast (expedited) coverage determination or appeal, the complaint will be responded to within 24 hours.

If you would like information on the aggregate number of Medicare Advantage grievances and appeals filed with Healthfirst, please contact Healthfirst Member Services at 1-888-260-1010, (TTY 1-888-542-3821 ), 8am–8pm, 7 days a week (October to March), and 8am–8pm, Monday to Friday (April to September).

You have the option to submit complaints/grievances directly through Medicare.gov. You can also access additional support through them, including help from an Ombusdman.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Healthfirst Medicare Plan has HMO and PPO plans with a Medicare contract. Our SNPs also have contracts with the NY State Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

ATENCIÓN: Dispone de servicios de asistencia lingüística y otras ayudas, gratis. Llame al 1-866-305-0408 (TTY: 1-888-867-4132).

请注意：您可以免费获得语言协助服务和其他辅助服务。请致电 1-866-305-0408 (TTY: 1‑888‑542‑3821)。

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