Medicaid : New York Healthy Choice Appeals

There are some treatments and services that you need to get approval for before you get them. Or you must get approval to keep getting them. This is called prior authorization. Asking us to OK a treatment or service is called a service authorization request. This process is described earlier in this handbook. Sometimes we turn down a service authorization request. Or we approve it for an amount that is less than requested. These decisions are called actions.  If you are not satisfied with our decision about your care, there are steps you can take.

 

Your provider can ask for reconsideration:

• Your doctor may ask us about service authorization requests. He or she can contact the plan’s medical director. The medical director will talk to your doctor within one work day.

You can file an action appeal:

• You can file if you are not satisfied with an action we took or what we decided about your service authorization request. You have 60 business days after hearing from us to file an appeal.
• You can do this yourself. Or you can ask someone you trust to file the appeal for you. You can call Customer Service at 1-800-288-5441 (TTY/TDD: 1-877-247-6272). They will help you file an appeal.
• We will not treat you any differently or act badly toward you because you file an appeal.
• The appeal can be made by phone or in writing. If you make an appeal by phone, it must be followed up in writing to:

Your action appeal will be reviewed under the fast-track process if:

• If you or your doctor asks to have your appeal reviewed under the fast-track process. Your doctor would have to tell us how a delay will harm your health. If your request for fast track is denied we will tell you. Then your appeal will be reviewed under the standard process;
  or
• If your request was denied when you asked to keep getting care that you are now getting or need to extend a service that has been provided.

Fast-track appeals can be made by phone. They do not have to be followed up in writing.

 

What happens after we get your appeal:

• Within 15 days, we will send you a letter to let you know we are working on your appeal.
• Action Appeals of clinical matters will be decided by qualified health care professionals. They will not be people who made the first decision. At least one will be a clinical peer reviewer.
• Non-clinical decisions will be handled by persons who work at a higher level than the people who worked on your first decision.
• Before and during the appeal you or your designee can see your case file. This includes medical records. It also includes any other records used to make a decision on your case.
• You can also provide information to be used in making the decision in person or in writing.
• We will tell you why we decided they way we did. We will tell you our clinical rationale, if it applies. If you are still not satisfied, we will tell you about any further appeal rights you have. Or you or someone you trust can file a complaint with the New York State Department of Health at 1-800-206-8125.

Last modified: 05/27/2010