Grievances and Appeals

SERVICE AUTHORIZATIONS

A member or provider can request Prior Authorization for a new service, whether for a new authorization period or within an existing authorization period, or a request to change a service as determined in the plan of care for a new authorization period.

An Expedited Prior Authorization Request will be decided within 72 hours of receipt of request for services if the plan determines or the provider indicates that a delay would seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.

A Standard Prior Authorization Request will be decided within 3 business days of receipt of all necessary information, but no more than 14 days of receipt of request for services.

A Concurrent Review is a request by the member or provider on the member’s behalf for additional services that are currently authorized or home care following an inpatient hospitalization.

An Expedited Concurrent Review Request will be decided within 1 business day of receipt of all necessary information, but no more than 72 hours of receipt of request for services.

A Standard Concurrent Review Request will be decided within 1 business day of receipt of all necessary information, but no more than 14 days of receipt of request for services.

In the case of a request for Medicaid home health care covered services following an inpatient admission, 1 business day after receipt of necessary of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, 72 hours after receipt of necessary information; but in any event no more than 3 business days after receipt of the request for services.

Extension up to 14 calendar days may be requested by the member or provider on the member’s behalf written or verbal. The plan may also initiate an extension if it can justify need for additional information and if the extension is in the member’s interest.

If the plan denies a member’s request for an expedited review, the plan will handle as a standard review. Members or providers may appeal plan decisions (see appeal procedures below).

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 VNS Health MLTC. ICAN may be reached toll-free at 1-844-614-8800 or online at www.icannys.org.

FILING AN APPEAL

An appeal is the type of complaint you make when you want us to reconsider or change a plan decision. 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 refuses 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.

To file an appeal, write to:

VNS Health
Health Plans – MLTC Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523

An appeal may be filed orally or in writing. Appeals must be requested within sixty (60) days of the date of the notice of adverse benefit determination, which is a plan decision notice that is not fully in a member’s favor.

Aid Continuing while appealing a decision about your care:

Members have the right upon timely filing of an appeal — 10 days of the notice of adverse benefit determination or by the effective date of the adverse determination, whichever is later — for Aid Continuing. Aid Continuing applies when:

• If the plan decides to terminate, suspend, or reduce a previously authorized service during the period for which a service was approved; or
• If a member is in receipt of long-term services and supports or nursing home services (long or short) and the plan decides to partially approve, terminate or suspend, or reduce the level or quantity of long-term services and supports or nursing home stay (long and short) for a subsequent authorization period of such service.  

You can also call your Care Team at 1-888-867-6555 (TTY/TDD users, please call 711), if you need help filing an action appeal. Interpreter services are also available.

WHAT IS THE DIFFERENCE BETWEEN A “STANDARD” AND AN “EXPEDITED” APPEAL FOR MEDICAL CARE?

If you or your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the adverse benefit determination. We will respond to you within 72 hours of receiving your appeal request. The review period may be extended up to 14 days if you request an extension or if we need more information and the delay is in your best interest. The plan will make all reasonable efforts to give prompt oral notice of an extension and written notice within 2 calendar days. A decision about whether we will cover medical care can be a “standard decision” that is made within the standard time frame of 30 calendar days of receipt of the appeal request. The plan will send a written acknowledgment of appeal within 15 days of receipt. If a decision is reached before the written acknowledgment is sent, the plan will include the written acknowledgment with the notice of decision (one notice).

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

If we deny a member’s request to file an expedited appeal, the appeal will be processed under the standard timeframe and a determination will be made within 30 calendar days. The Plan will notify the member orally that their expedited request will be handled under the standard timeframe and will send a written notice of our decision to deny the expedited appeal request within 2 calendar days of receiving the request.

WHAT IS A STATE FAIR HEARING?

Members have the right to request a State Fair Hearing and have their case reviewed by an Administrative Law Judge from the NYS Office of Temporary and Disability Assistance (OTDA) if the Plan’s decision about an appeal is not in fully in the member’s favor. A Fair Hearing must be requested within 120 days of the plan’s appeal decision. OTDA will issue a written decision to either uphold or reverse the plan’s decision. However, the State of New York requires that members exhaust the plan’s internal appeal process before a fair hearing is requested.

WHAT IS AN EXTERNAL APPEAL?

If an appeal is denied because it is determined that the service is not medically necessary, is experimental or investigational, or the services could be provided by an in-network provider, members may file an external appeal with New York State. Members have the right to file an external appeal within 4 months of the notice of appeal decision. The external appeal is decided by external reviewers who do not work for us or New York State. These reviewers are qualified people approved by New York State. You do not have to pay for an external appeal. Your external appeal will be decided within 30 days. More time (up to 5 business days) may be needed if the external appeal reviewer asks for more information. You can get a faster decision (expedited external appeal) if your doctor can say that a delay will cause serious harm to your health. The external appeal reviewer will decide an expedited appeal in 3 calendar days or less. The reviewer will tell you and the plan the decision right away by phone or fax; followed by a letter with the decision. You may request both a State Fair Hearing and external appeal at the same time. If you ask for both a Fair Hearing and external appeal, the decision of the Fair Hearing Officer is the final decision.

FILING A COMPLAINT

A complaint is an expression of dissatisfaction with any matter other than a “Plan Decision” by the member or provider on the member’s behalf about care and treatment. For example, you could file a complaint if:

• You are having a problem with the quality of 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 receiving your services or items in a timely manner.

Expedited and Standard Complaint and Complaint Appeal

The plan will send a written acknowledgment of the complaint within 15 business days of receipt. If a decision is reached before the written acknowledgment is sent, the plan may include the written acknowledgment with the notice of decision (one notice).

An expedited complaint will be decided as fast as the member’s condition requires, but no more than 48 hours of receipt of all necessary information or 7 calendar days of receipt of the complaint. The Plan will notify members of the decision by phone and in writing within 3 business days of the decision.

A Standard complaint will be decided 45 calendar days of receipt of all necessary information but no more than 60 calendar days of receipt of the complaint. 

Members have 60 business days after receipt of a complaint decision to file a written complaint appeal. Expedited complaint appeals will be decided within 2 business days of receipt of all necessary information. Standard complaint appeals will be decided within 30 business days of receipt of all necessary information. There is no further complaint levels after a complaint appeal.

You can file a complaint orally by calling your Care Team at 1-888-867-6555. (TTY/TDD users, please call 711). Interpreter services are also available or in writing at:
VNS Health
Health Plans – MLTC Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523