Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.
Making an appealIf we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
How to make a Level 1 Appeal (How to ask for a review of a medical care coverage decision made by our plan)
Step 1: You contact us and make your appeal. If your health requires a quick response, you must ask for a "fast appeal."
What to do
If your health requires it, ask for a “fast appeal” (or you can make a request by calling us)A “fast appeal” is also called an "expedited reconsideration."
Step 2: We consider your appeal and we give you our answer.
Deadlines for a “fast” appeal
Deadlines for a “standard” appeal
Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.
The formal name for “making a complaint” is “filing a grievance”
Step 1: Contact us promptly – either by phone or in writing.
For Medical Grievances:
You can send your written complaint to Affinity Health Plan Customer Service/Medicare, Affinity Health Plan, Metro Center Atrium, 1776 Eastchester Road, Bronx, NY 10461.
After we receive your written grievance, you will receive an acknowledgement letter from us within 5 days. The letter will summarize your grievance, tell you who is working to resolve your grievance, how to contact this person, and whether we need more information from you. You will receive a letter from us within 24 hours if your grievance involves a decision to not conduct an expedited organization/coverage determination or reconsideration or to take extensions on initial decision or appeals. If you disagree with this decision, you can file an expedited grievance with our plan. We must notify you by mail of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
Step 2: We look into your complaint and give you our answer.
You can also submit a complaint directly to Medicare. To submit a complaint to Medicare, go to http://www.medicare.gov/MedicareComplaintForm/home.aspx. If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1.800.MEDICARE (1.800.633.4227). TTY/TDD users can call 1.877.486.2048.