Affinity Health Plan

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  • Appeals and Grievances Process

    Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

    Making an appeal
    If 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 

    • To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing. 
    • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. Write a letter describing your appeal, and include any paperwork that may help in the research of your case.  Send the appeal request to Affinity Health Plan, A&G Unit- Quality Management Department, Metro Center Atrium, 1776 Eastchester Road, Bronx, NY 10461.  You may also ask for an appeal by calling us at 1-888-543-9069. Calls to this number are free. We are open 8:00am to 8:00 pm, Monday through Sunday. TTY users can call 1-800-662-1220.
      • If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Customer Services (phone numbers are printed on the back cover of this booklet) and ask for the “Appointment of Representative” form. It is also available on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf .) While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed.  If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.
       
    • If you are asking for a fast appeal, make your appeal in writing or call us at 1-888-543-9069. Calls to this number are free. We are open 8:00am to 8:00 pm, Monday through Sunday. TTY users can call 1-800-662-1220.
    • 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. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
    • You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
      • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you.
      • If you wish, you and your doctor may give us additional information to support your appeal.
       

    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."

    • If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”
    • To start a fast appeal you, your doctor, or your representative, must contact us either by phone or in writing.  Send the fast appeal request to Affinity Health Plan, A&G Unit- Quality Management Department, Metro Center Atrium, 1776 Eastchester Road, Bronx, NY 10461. You may also ask for a fast appeal by calling us at 1-888-543-9069. Calls to this number are free. We are open 8:00am to 8:00 pm, Monday through Sunday. TTY users can call 1-800-662-1220.
    • If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal.

    Step 2: We consider your appeal and we give you our answer. 

    • When we are reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.
    • We will gather more information if we need it. We may contact you or your doctor to get more information.

    Deadlines for a “fast” appeal

    • When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
      • However, 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 we decide to take extra days to make the decision, we will tell you in writing.
      • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.
       
    • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal. 
    • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.

    Deadlines for a “standard” appeal

    • If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
      • However, 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 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 deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
       
    • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
    • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 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. 

    • To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. 

    Filing a Grievance

    The formal name for “making a complaint” is “filing a grievance”

    Step 1: Contact us promptly – either by phone or in writing. 

    • Usually, calling Customer Services is the first step. If there is anything else you need to do, Customer Services will let you know. You can call us at 1-877-234-4499. Calls to this number are free. We are open 8:00am to 8:00pm, Monday through Sunday. TTY users can call 1-800-662-1220.
    • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint 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.

    • Whether you call or write, you should contact Customer Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
    • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
      • What this section calls a “fast complaint” is also called an “expedited grievance.”
       

    Step 2: We look into your complaint and give you our answer. 

    • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
    • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
    • If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

    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.

  • H5991_AffinityMedicarePlanWebsite2017 Approved 10/01/2016 Last updated 03/07/2017