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:

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.

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).

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).