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Grievances and Appeals

2021 VNSNY CHOICE Total (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:

TIMEFRAMES FOR COVERAGE DECISIONS:

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:

TIMEFRAMES FOR APPEALS:

You must make your appeal request within 60 calendar days from 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:

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:

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:

COMMON QUESTIONS ABOUT FILING AN APPEAL OR COMPLAINT

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