Medicare Advantage Grievance and Appeals

This is a Medicare-related page; some of the links will take you to non-Medicare information or to a different website.

FILING AN APPEAL
An appeal is the type of complaint you make when you want us to reconsider or change a decision about your health care service. For example, you could file an appeal if:
We refuse to cover or pay for a service you think we should cover.
We or one of our providers refuse to give you a service you think should be covered.
We or one of our plan providers reduces or cuts back on a service you have been receiving.
You think we are stopping your coverage for a service too soon.
 
FILING AN ORGANIZATION DETERMINATION
An Organization Determination is any determination made by the health plan or its delegated providers to pay partially or not pay for an item or service.  A member, a member's representative, or any provider that furnishes, or intends to furnish, services to a member, may request a standard organization determination by filing a request with VNSNY CHOICE. Expedited requests may be requested by a member, a member’s representative, or any physician, regardless of whether the physician is affiliated with the health plan.
 
FILING A PART D EXCEPTION
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.
     
If you or your doctor believes you should take a prescription that is not on the VNSNY CHOICE formulary, you may file an appeal called an exception using the Request for Medicare Prescription Drug Coverage Determination form

To file an oral exception request, please call Member Services at 
1-866-783-1444. (TTY/TDD users, please call 711) Interpreter services are also available.
Representatives are available 7 days a week, 8:00 AM to 8:00 PM. 

FILING A GRIEVANCE 
A grievance is the type of complaint you make if you are dissatisfied with the quality of care you receive from VNSNY CHOICE or one of our providers. For example, you could file a grievance if:
  • You are treated rudely by anyone connected with your care.
  • You are unable to reach someone by phone or get the information you need.
  • You have trouble scheduling appointments in a timely manner.
  • 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.
For more information, see Common Questions about Filing an Appeal or Grievance.

Common Questions about Filing an Appeal or Grievance
Following are frequently asked questions about filing an appeal or grievance.

What is the difference between a "standard" and a "fast" or "expedited" appeal for Medical Care?

What if a member's request for an expedited review is denied?

What if a member wants to appeal a discharge from Facility Based Care?

How Do I File a Grievance or Appeal?

How can Members obtain an aggregate number of grievances, appeals and exceptions filed with the plan?

What rights and responsibilities do members have upon disenrollment from VNSNY CHOICE Medicare?

What are my protections in this plan?

 

WHAT IS THE DIFFERENCE BETWEEN A "STANDARD" AND A "FAST" OR "EXPEDITED" DECISION FOR MEDICAL CARE?

A decision about whether we will cover medical care can be a "standard decision" that is made within the standard time frame (typically within 14 days; see below), or it can be a "fast decision" that is made more quickly (typically within 72 hours; see below). A fast decision is sometimes called a 72-hour decision or an "expedited organization determination."
 

You can ask for a fast decision only if you or any doctor believes that waiting for a standard decision could seriously harm your health or 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.)
 
Members may also request an appeal for any coverage determination made by VNSNY CHOICE Medicare. When VNSNY CHOICE Medicare makes a coverage determination, we are deciding whether to provide or pay for covered medical services or prescription drugs and what your share of the cost will be. Members have the right to file an appeal if they would like VNSNY CHOICE Medicare to reconsider and change a decision made concerning medical services, prescription drug benefits, or the share of the costs that the member is responsible for paying.
 

WHAT IF A MEMBER’S REQUEST FOR AN EXPEDITED REVIEW IS DENIED?

If VNSNY CHOICE denies a member’s request to file an expedited organization determination, we will process the request under the standard timeframe and make a determination within 14 calendar days. The Plan will notify the member 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 grievance; 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 seriously jeopardize the life or  health of the member or the member’s ability to regain maximum function; the request will be expedited.  
 

WHAT IF A MEMBER WANTS TO APPEAL A DISCHARGE FROM FACILITY BASED CARE?

A member has the right, by law, to ask for a review of a discharge date from the Hospital, SNF, HHA, or CORF. Members must contact the Quality Improvement Organization (QIO) for review. If a member believes he or she is being discharged too soon, he or she must fill out a Notice of Discharge & Medicare Appeal Right (link coming soon).

This notice will tell you:
  • Why you are being discharged
  • The date that we will stop covering your hospital stay (stop paying our share of your hospital costs)
  • What you can do if you think you are being discharged too soon,
  • Whom to contact for help
If a member does not ask the QIO for a "fast appeal" by the deadline (no later than noon on the day before the date the members' Medicare coverage ends), the member may ask VNSNY CHOICE Medicare for a "fast appeal" of their discharge.

For more information on member appeal and grievance rights, please refer to the Member Handbook (Evidence of Coverage) for Medicare Maximum, Medicare Preferred, and Medicare Classic, or the Summary of Benefits for Medicare Maximum, Medicare Preferred, Medicare Classic, or contact us.  
 

HOW DO I FILE A GRIEVANCE OR APPEAL?

To file an oral grievance or request an appeal, please:
  • Call Member Services at 1-866-783-1444 (for TTY, please call 711). Interpreter services are also available.
    (Representatives are available 7 days a week, 8:00 AM to 8:00 PM)
  • Fax to: 1-866-791-2213
  • Members may also mail appeals to:
VNSNY CHOICE 
Medicare Grievance & Appeals 
P.O. Box 445
Elmsford, NY 10523
 
If you are not satisfied with the outcome of your appeal, you have the right to an external appeal from an organization or judge not affiliated with VNSNY CHOICE Medicare. Please refer to the Member Handbook (Evidence of Coverage), or the Summary of Benefits for Medicare Maximum, Medicare Preferred, Medicare Classic, or for more information about how to file an appeal, contact us. To appoint a representative to act on your behalf, please use the Appointment of Representative form (CMS-1696) in English or en español.
 
How do I file an External Grievance: You or your authorized representative may also file an external grievance with the Centers for Medicare and Medicaid Services (CMS) by:
Phone: 1-800-Medicare, 24 hours a day/7 days a week
 
TIMEFRAMES FOR FILING APPEALS:
You, your providers, and your representatives have 60 calendar days to file an appeal related to denial or reduction or termination of authorized Medicare or Medicaid benefit coverage. 
a. Expedited Service Appeals: Notification of a decision will be made within 24 hours in certain circumstances. For all other circumstances where a standard decision would significantly increase the risk to your health, a decision and notification will be made within 72 hours after we receive all necessary information. VNSNY CHOICE may extend the timeframe by up to 14 calendar days if the member requests the extension or if we need additional information and the extension of the time benefits you.
 b. Standard Service Appeals: Notification of a decision will be given within 30 calendar days of receiving the written or oral appeal. VNSNY CHOICE Medicare may extend the 30 calendar day timeframe by up to 14 calendar days if the member or a provider on your behalf (written or oral) requests the extension or if VNSNY CHOICE justifies a need for additional information in the interest of the member. 
c. Claim Appeals: Notification of a decision will be made within 60 calendar days of receiving the appeal. No extension may be taken on payment appeals.
 
TIMEFRAMES FOR FILING AN ORGANIZATION DETERMINATION:
a. Expedited Organization Determination: Notification of a decision will be given as quickly as the member’s health condition requires but no later than 72 hours of receiving the request. VNSNY CHOICE may extend the timeframe by up to 14 calendar days if the member requests the extension or if we need additional information and the extension of the time benefits you.
 b. Standard Organization Determination: Notification of a decision will be given as quickly as the member’s health condition requires but no later than 14 calendar days of receiving the request. VNSNY CHOICE may extend the timeframe by up to 14 calendar days if the member requests an extension or VNSNY CHOICE may grant itself an extension if it is in the best interest of the member. 
c. Claim Organization Determinations: Notification of a decision will be made within 30 calendar days for claims from non-contracted providers and all other claims within 60 calendar days.
 
TIMEFRAMES FOR FILING GRIEVANCES:
All grievances must be filed within 60 calendar days of the incident or whenever there is dissatisfaction. 
a. Expedited: Notification of a decision will be made within 24 hours in certain circumstances. For all other circumstances where a standard decision would significantly increase the risk to your health, a decision and notification will be made within 48 hours after we receive all necessary information and no later than 3 calendar days 
b. Standard: Notification of a decision will be given within 30 calendar days of receiving the written or oral grievance. VNSNY CHOICE Medicare may extend the 30 calendar day timeframe by up to 14 calendar days if the member or a provider on your behalf (written or oral) requests the extension or if VNSNY CHOICE justifies a need for additional information in the interest of the member. 

HOW CAN MEMBERS OBTAIN AN AGGREGATE NUMBER OF GRIEVANCES, APPEALS AND EXCEPTIONS FILED WITH THE PLAN?

To obtain an aggregate number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-783-1444, 7 days a week, 8:00am – 8:00pm (TTY/TDD users: 711). Interpreter services are also available.
or reach us by mail at:
VNSNY CHOICE 
Medicare Appeals and Grievances 
P.O. Box 445
Elmsford, NY 10523
For more information on appeals and grievances, please see the section above.
 

WHAT RIGHTS AND RESPONSIBILITIES DO MEMBERS HAVE UPON DISENROLLMENT FROM VNSNY CHOICE MEDICARE?

"Disenrollment" from VNSNY CHOICE Medicare means ending your membership in VNSNY CHOICE Medicare. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):
  • You might leave VNSNY CHOICE Medicare because you have decided that you want to leave. You can do this at any time for any reason.
  • There are also a few situations where you would be required to leave. 
  • For example, you would have to leave VNSNY CHOICE Medicare if you move permanently out of our geographic service area or if VNSNY CHOICE Medicare leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.
To disenroll, you may: 
  • Call Member Services at 1-866-783-1444 (TTY/TDD users: 711). Representatives are available Monday through Friday, 8:00 AM to 8:00 PM. Interpreter services are also available.
  • Call 1-800-Medicare
  • Mail your written disenrollment request to:
VNSNY CHOICE Medicare
PO Box 4497 
Scranton, PA 18505
 
For more information on plan premiums, please refer to the Member Handbook (Evidence of Coverage) Medicare Maximum, Medicare Preferred, Medicare Classic, or the Summary of Benefits, or contact us.  
 

WHAT ARE MY PROTECTIONS IN THIS PLAN?

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.

Last updated 1/2/2019