VNSNY CHOICE EasyCare (HMO) and VNSNY CHOICE EasyCare Plus (HMO D-SNP) Grievances and Appeals
If you have Medicare and get assistance from Medicaid, the information below applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes.
FILING AN ORGANIZATION DETERMINATION (ALSO KNOWN AS A “COVERAGE DECISION” OR AN “ACTION”)
A Coverage Determination is when the plan, or delegated vendor has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called “coverage decisions.” You, your representative, or any provider that furnishes, or intends to furnish, services to you, may request an organization determination by filing a request with VNSNY CHOICE.
FILING A PART D EXCEPTION (WHICH IS ALSO A “COVERAGE DECISION” OR AN “ACTION”)
If a drug is not covered in the way you would like it to be covered, you can ask VNSNY CHOICE to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
Covering a Part D drug for you that is not on our plan’s List of Covered Drugs(Formulary)
Removing a restriction on the plan’s coverage for a covered drug
Changing coverage of a drug to a lower cost-sharing tier
TIMEFRAMES FOR COVERAGE DECISIONS:
Standard Coverage Decision – Generally, on a request for a medical item or service, we will give you our answer within 14 calendar days after receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours of receiving your request.
For Medical Item or Service – Fast Coverage Decision is called an integrated expedited determination. A fast coverage decision means we will answer within 72 hours of your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
For coverage decision about the drug(s) or payment – Fast Coverage Decision is called an expedited coverage determination: We will give you an answer within 24 hours after we receive your doctor’s statement.
Claim Coverage Determinations – Notification of a decision will be made within 30 calendar days of receipt if they are submitted by you, or on your behalf or are claims that are not furnished under a written agreement between the plan and the provider. Claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request.
FILING AN APPEAL
If we say no to your coverage decision, you have the right to ask for an appeal. Asking for an appeal means asking us to reconsider — and possibly change — the decision we made. You may also ask for an appeal if you disagree with our decision to stop services that you are receiving. For example, you could file an appeal if:
We refuse to cover or approve a service you think we should cover.
We refuse to pay for a service that was provided to you and you think we should pay for the service.
We reduce or cut back on a service you have been receiving.
You think we are stopping your coverage for a service too soon.
TIMEFRAMES FOR APPEALS:
You must make your appeal request within 60 calendar daysfrom the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Please include your reason in your appeal request.
Our timeframes to respond to your appeal are as follows:
“Fast” Appeal: When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal, this includes fast appeals for Medicare Part B drugs. If you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide to take extra days to make the decision, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug or a payment appeal.
Standard Appeals: If we are using the standard deadlines, we must give you our answer on a request for a medical item or service within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. If your request is for a Medicare Part B prescription drug, we will give you our answer within 7 calendar days after we receive your appeal if your appeal is about coverage for a Part B prescription drug you have not yet received. We will give you our decision sooner if your health condition requires us to.
If you ask for more time or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide we need to take extra days to make the decision, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug or a payment appeal.
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
If we do not give you an answer by the applicable deadlines above (or by the end of the extended time we took on your request for a medical item or service), we are required to send your request on to Level 2 of the appeals process. Then an independent outside organization will review it. For more information, please refer to your Member Handbook or call your Care Team.
FILING A COMPLAINT (ALSO KNOWN AS “FILING A GRIEVANCE”)
A complaint is a process our members can use for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. If your problem is related to benefits, coverage decisions, or payment, please refer to the coverage decision and appeal sections above. Some examples of problems that would follow the complaint process are:
You are treated rudely by anyone connected with your care such as your doctors, pharmacy, other health care providers, or plan representatives.
You are unable to reach someone by phone or get the information you need.
You are unhappy with the quality of care you received from a doctor or health care facility such as a clinic or hospital.
You have a problem with your doctor’s office, whether it is the condition or cleanliness of the doctor’s office, or you are kept too long in the waiting room.
We took too long to answer your coverage decision request, or appeal.
For more information, see Common Questions about Filing an Appeal or Complaint, below.
TIMEFRAMES FOR FILING COMPLAINTS:
There is no time limit to filing a complaint, you can make the complaint at any time after you had the problem. We do recommend however that you file your complaint as soon as you are able to and provide as much information as you can to help us understand your problem and help resolve it sooner.
Our timeframes to respond to complaints are:
“Fast” Complaints: If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” or if we extended the timeframe of your coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
Standard Complaints: Notification of a decision will be given within 30 calendar days of receiving the written or oral complaint. VNSNY CHOICE EasyCare and EasyCare Plus may extend the 30 calendar day timeframe by up to 14 calendar days if you or a provider on your behalf (written or oral) requests the extension or if VNSNY CHOICE justifies a need for additional information because it is in your best interest.
COMMON QUESTIONS ABOUT FILING AN APPEAL OR COMPLAINT
Below are frequently asked questions about filing an appeal or complaint.
You can ask for a fast coverage decision only if you or any doctor believes that waiting for a standard coverage decision could cause serious harm to your health or hurt your ability to function. Fast decisions apply only to requests for medical care. You cannot get a fast decision on requests for payment for care you have already received.
If VNSNY CHOICE denies your request to file an expedited coverage decision, we will process the request under the standard timeframe and make a decision within 14 calendar days. The Plan will notify you orally and in writing within 3 calendar days that their expedited request will be handled under the standard timeframe, the member’s right to file an expedited complaint; including the process and timeframe, the right to resubmit a request for an expedited determination and that if the member obtains any physician support indicating that applying the standard timeframe for making a determination could cause serious harm to you or hurt your ability to function, the request will be expedited.
You have the right, by law, to ask for a review (an appeal) of a discharge date from the Hospital, Skilled Nursing Facility, Home Health Aide services, or Comprehensive Outpatient Rehabilitation Facility. You must contact the Quality Improvement Organization (QIO) for review. If you believe that you are being discharged too soon and appeal, you will receive a Detailed Notice of Discharge. The Detailed Notice of Discharge explains the specific reasons for the discharge. You can see a sample notice online at www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html.
If you do not ask the QIO for a “fast appeal” by the deadline (no later than noon on the day after the date your Medicare coverage ends), you may ask VNSNY CHOICE EasyCare and EasyCare Plus for a “fast appeal” of the discharge.
To file a complaint or request an appeal, please either: Call us at 1-866-783-1444 (TTY: 711). 8 am – 8 pm, 7 days a week; or,
Members may also submit their appeals or complaints in writing and mail or fax to:
To obtain the total number of complaints, appeals, and exceptions filed with the plan, please call us at 1-866-783-1444 (TTY; 711), 8 am – 8 pm 7 days a week.
Call your VNSNY CHOICE Care Team at 1-866-783-1444 (TTY: 711), 7 days a week, from 8 am – 8 pm.
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If your plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
If you have Medicare and get assistance from Medicaid, the information below applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes.
