Grievances Exceptions Coverage Determinations Appeals
User Manual: Grievances-Exceptions-Coverage-Determinations-Appeals
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Grievance, Organization/ Coverage Determinations and Appeals GuildNet Gold Plus FIDA Plan MMP-POS is a health plan that contracts with both Centers for Medicare and Medicaid (Medicare) and the New York State Department of Health (Medicaid) to deliver and coordinate all components of Medicare and Medicaid Covered Items and Services for Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Our FIDA Plan is not only committed to providing you with the high quality of services you deserve but to also improving Participant satisfaction. If you have a complaint related to our plan, providers, or pharmacies, please call our Participant Services Department at 1-800-815-0000, Monday – Sunday 8:00am to 8:00pm and we will do our best to assist you over the phone. TTY users should call 711. You can also write to us at 250 West 57th Street, 10th Floor, New York, NY 10107. You can get help from the Independent Consumer Advocacy Network (ICAN) If you need help getting started, you can always call ICAN. ICAN can answer your questions and help you understand what to do to handle your problem. ICAN is not connected with GuildNet Gold Plus FIDA Plan or with any insurance company or health plan. ICAN can help you understand your rights and how to share your concerns or disagreement. ICAN can also help you in communicating your concerns or disagreement with us. The toll-free phone number for ICAN is 1-844-614-8800 (TTY 711). The services are free. You can get help from the State Health Insurance Assistance Program You can also call your State Health Insurance Assistance Program (SHIP). In New York State, the SHIP is called the Health Insurance Information, Counseling, and Assistance Program (HIICAP).The HIICAP counselors can answer your questions and help you understand what to do to handle your problem. The HIICAP is not connected with us or with any insurance company or health plan. The HIICAP has trained counselors and services are free. The HIICAP phone number is 1-800-701-0501. Getting help from Medicare You can also call Medicare directly for help with problems. Here are two ways to get help from Medicare: Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. The call is free. Visit the Medicare website (http://www.medicare.gov). There is a direct link on our website at www.guildnetny.org. H0811_GN117_Web15_BeneficiaryProtections_Approved Complaints and Appeals Our Participants have the right to make complaints and ask us to reconsider decisions we have made. When you have a problem about our decision related to benefits, coverage or payment, you can file an appeal and we will reconsider our decision. When you have other problems related to your quality of care, our plan, providers or pharmacies, you can file a grievance. You can also refer to Chapter 9 of the Participant Handbook or go to the link below for more information about appeals and grievances. Grievances You or your appointed representative may file a grievance to our plan by calling our Participant Services number at 1-800-815-0000 (TTY 711), Monday through Sunday, 8 a.m. to 8 p.m. or in writing to 250 West 57th Street, 10th Floor, New York, NY 10107. If we cannot resolve your issue over the phone, we will resolve it as quickly as possible, but no later than thirty (30) calendar days from the date our plan receives your request. We may take more time, up to fourteen (14) days, if we need additional information. We will notify you of our decision in writing. Most grievances are answered in 30 calendar days. If possible, we will answer you right away. If you call us with a grievance, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. If you need a response faster because of your health, we will give you an answer within 48 hours after we get all necessary information (but no more than 7 calendar days from the receipt of your grievance). If you are filing a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will respond to your grievance within 24 hours. If you are filing a grievance because we took extra time to make a coverage decision, we will respond to your grievance within 24 hours. If we do not agree with some or all of your grievance, we will tell you and give you our reasons. We will respond whether we agree with the grievance or not. If you disagree with our decision, you can file an external grievance. You can tell Medicare about your grievance You can send your grievance (complaint) to Medicare. The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free. 2 Your grievance will be sent to the Medicare and Medicaid team overseeing GuildNet Gold Plus FIDA Plan and the FIDA Program. You can tell the New York State Department of Health about your grievance To file a grievance with the New York State Department of Health (NYSDOH), call the NYSDOH Helpline at 1-866-712-7197. Your grievance will be sent to the Medicare and Medicaid team overseeing GuildNet Gold Plus FIDA Plan and the FIDA Program. You can file grievances about disability access or language assistance with the Office of Civil Rights If you have a grievance about disability access or about language assistance, you can file a grievance with the Office of Civil Rights at the Department of Health and Human Services at Office for Civil Rights U.S. Department of Health and Human Services Jacob Javits Federal Building 26 Federal Plaza - Suite 3312 New York, NY 10278 Voice Phone (800) 368-1019 FAX (212) 264-3039 TDD (800) 537-7697 Coverage Decisions Your Interdisciplinary Team (IDT) or the Plan makes coverage decisions whenever a decision is made about what is covered for our Participants or how much the plan will pay. Coverage decisions may also involve issues related to payment for services or drugs already obtained. We handle decisions about medical coverage differently from prescription drug coverage decisions. Organization Determinations Organization Determinations are coverage decisions your Interdisciplinary Team (IDT) or the Plan makes on medical and prescription services (for example, hospital stay and doctor or outpatient services). For prescriptions, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement. 3 For medical determinations, the Plan has 3 days after the request for service to make an initial determination. If the Plan needs more information to make a determination, we may request an extension of 3 more days. Coverage determinations for continued or extended health services to continue an ongoing course of treatment must be made within 1 business day upon receipt of all necessary information. If you request an expedited decision, the Plan will make a decision about your medical care within 24 hours. In some cases, the Plan can extend this deadline another 3 days. The Plan will make a decision about whether you meet the criteria for an expedited coverage decision. To request an Organization Determination you, your provider or authorized representative should call us at 1-800-815-0000, TTY 711 Monday through Sunday 8 am to 8 pm. Or write to GuildNet Gold Plus FIDA Plan, 250 West 57th Street, 10th Floor, New York, NY 10107. . Appeals What is an Appeal? If you do not agree with the Plan’s coverage determination and would like a review of an Action taken by the plan, you may ask us to reconsider our decision. This is called an appeal. You have the right to make complaints and to ask us to reconsider decisions we have made. When you have a problem about our decision related to benefits, coverage or payment, you can file an appeal and we will reconsider our decision. When you have other problems related to your quality of care, our providers or pharmacies, you can file a grievance. There is one integrated Medicare-Medicaid appeal process for all services including Medicaid drugs. For Medicare Part D drug coverage, the Plan uses the standard Part D appeals process. How to Request an Appeal Appeals for Part D drug and non-Part D drugs To make an appeal or complaint about your Part D coverage, please call 1-877-866-5828 (TTY 711) or fax to 212-510-5320. You must make your appeal within 60 days from the date of the notice we sent that responded to your original request. We are open Monday through Sunday 8 am to 8 pm. Or write to GuildNet, ATTN: Grievance and Appeals P.O. Box 2807, New York, NY 10116-2807. If you need to appeal a decision about your Medicaid covered drugs, please contact your Care Manager or Participant Services. You can request an expedited (fast) appeal for prescription drug coverage if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. We 4 will automatically expedite your request, if your prescriber asks us to. If your request to expedite is granted, we must make a decision no later than 72 hours after receiving your appeal. Appeals for Medicare or Medicaid items and services Within 60 days of a denial, termination or reduction in services, you may request an appeal (either verbally or in writing). You just need to let us know the organization determination you would like to appeal, whether the request is expedited or standard, and any additional information to consider when making a decision. You, your provider or your authorized representative may file an appeal. GuildNet Gold Plus FIDA Plan will provide free interpreter services and written material in Spanish, Chinese, Russian, Italian, Haitian-Creole, and Korean or in alternative formats (Braille, large print, etc.) if needed. Please let us know if you need this information in another language. You can also contact ICAN at 1-844-614-8800 (TTY 711) for assistance in filing an appeal. If your appeal request occurs within ten days of notification about the termination or modification of previously authorized services, we will continue to provide these benefits while the appeal decision is pending. The Plan has 30 days from the date you requested the appeal to come to a decision. If your appeal is expedited, the Plan will provide a response within 72-hours of receipt. (Expedited appeals are granted when the timeframe for a standard decision will put your health at risk.) Who May Request an Appeal? You or someone you name to act for you (your appointed representative) may request 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. Complete the Appointment of Representative Form available on our website. You can fax or mail the form to us at the number or address listed above. What Do I Include with My Appeal Request? Whether you call or write, the information we need to address your appeal is Your name ID number Name of your authorized representative (if applicable) Contact information (how we can get in touch with you) Description of what happened (include provider name, if applicable) Date of incident Any documents that support your complaint (if applicable) 5 GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Program. As a Participant of GuildNet Gold Plus FIDA Plan, you have the right to get timely information and updates from us, including information about the total number of Participant grievances, appeals and exceptions filed with the Plan. If you have questions about GuildNet Gold Plus FIDA Plan or want to request this information, just call us at 1-800-815-0000 (TTY 711). This is a free service. You can get this information for free in other languages. Call 1-800-815-0000 (TTY 711), Monday through Sunday 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD al 711, de lunes a domingo de 8am a 8pm. La llamada es gratis.” The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844-6148800 (TTY 711) or online at icannys.org. 6
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