2020 VNSNY CHOICE Total 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.

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 any initial (first) decision made by the health plan or its delegated providers to make a decision about an item, service, or payment. 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 drug
  • Changing coverage of a drug to a lower cost sharing tier

TIMEFRAMES FOR COVERAGE DECISIONS:

  • Expedited Coverage Decision: Notification of a decision will be given as quickly as your 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 you request the extension or if we need additional information and the extension of the time benefits you.
  • Standard Coverage Decision: Notification of a decision will be given as quickly as your 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. 
  • Claim Coverage 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.

FILING AN APPEAL

An appeal is the type of complaint you make when you want us to reconsider or change a coverage decision about your health care service or payment of a 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.

TIMEFRAMES FOR 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. “Fast” Appeal: Notification of a decision will be made within 72 hours when a standard decision would cause serious harm to your health or hurt your ability to function, after we receive all the necessary information.

  • 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 appeal is for a medical item or service. If we decide to take extra days to make the decision, we will tell you in writing.
  • 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 deadline 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, called the “Integrated Administrative Hearing Office” will review it. For more information, please refer to your Member Handbook or call Member Services.

b. Standard Appeals: we will give you an answer within 30 calendar days after we receive your appeal for a medical item or service. If your appeal is for a Part D prescription drug, we will give you an answer within 7 days after we receive your appeal, and if your appeal is for payment of a Part D prescription drug, we will give you an answer within 14 days after we receive your appeal.

  • 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.
  • 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 deadline 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, called the “Integrated Administrative Hearing Office” will review it. For more information, please refer to your Member Handbook or call Member Services.

c. Claim Appeals: Notification of a decision will be made within 60 calendar days of receiving the appeal. If you are an out of network provider filing a claim appeal, a decision may take up to 120 days if a completed Waiver of Liability form is needed. No extension may be taken on payment appeals and payment appeals cannot be processed as “fast” appeals.

FILING A GRIEVANCE (also known as “Filing a Complaint”)

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 complaint 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 Complaint.

TIMEFRAMES FOR FILING COMPLAINTS:

All complaints 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 complaint. VNSNY CHOICE Total 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. 

Common Questions about Filing an Appeal or Complaint

Below are frequently asked questions about filing an appeal or complaint.

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

What if my request for an expedited review is denied?

What if I want to appeal a discharge from Facility Based Care?

How do I File a Complaint or Appeal?

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

What are my protections in this plan?

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

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.

WHAT IF MY REQUEST FOR A FAST COVERAGE REVIEW IS DENIED?

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.  

WHAT IF I WANT TO APPEAL A DISCHARGE FROM FACILITY BASED CARE?

You have the right, by law, to ask for a review (an appeal) of a discharge date from the Hospital, SNF, HHA, or CORF. 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 https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html.

If a member does not ask the QIO for a "fast appeal" by the deadline (no later than noon on the day after the date the members' Medicare coverage ends), the member may ask VNSNY CHOICE Total for a "fast appeal" of their discharge.

For more information on member appeal and complaint rights, please refer to the Member Handbook (Evidence of Coverage), or the Summary of Benefits, or contact us.  

HOW DO I FILE A COMPLAINT OR APPEAL?

To file an oral complaint or request an appeal, please:

  • Call Member Services at 1-866-783-1444 (TTY users call 711). Interpreter services are also available.
    (Representatives are available 7 days a week, 8 am –  8 pm.)
  • Fax to: 1-866-791-2213
  • Members may also submit their appeals or complaints in writing and mail to:

VNSNY CHOICE Total
Medicare Grievance & Appeals
P.O. Box 445
Elmsford, NY 10523

If you are not satisfied with the outcome of your appeal, details regarding your right to further appeal and your next steps will be included in your decision letter. Please refer to the Member Handbook (Evidence of Coverage) or the Summary of Benefits, or for more information, or please 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 Complaint

You or your authorized representative may also file an external complaint with the Centers for Medicare and Medicaid Services (CMS) by:

Phone: 1-800-MEDICARE, (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Submit complaints: https://www.medicare.gov/MedicareComplaintForm/home.aspx.

HOW CAN I OBTAIN THE TOTAL NUMBER OF COMPLAINTS, APPEALS, AND EXCEPTIONS FILED WITH THE PLAN?

To obtain the total number of complaints, appeals, and exceptions filed with the plan, please call us at 1-866-783-1444, 7 days a week, 8 am – 8 pm (TTY users call 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, please refer to the Member Handbook (Evidence of Coverage).

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 10/1/2019