Fidelis Care Medicare Organization: How to file a grievance, appeal or organization determination request
What is an Organization Determination? Any determination made by a Medicare health plan with respect to any of the following:
- Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
- Payment for any other health services furnished by a provider other than the Medicare health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan;
- The Medicare health plan’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the Medicare health plan;
- Reduction, or premature discontinuation of a previously authorized ongoing course of treatment;
- Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee;
What is a Grievance? Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility.
In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.
Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services (see Appeal).
What is an Appeal? Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service.
How to File a Grievance and/or an Appeal: As a member you or your authorized representative may file an organization determination, grievance and/or appeal within 60 days of the date of the event or incident by calling our Member Services Department at 1-800-247-1447 (TTY users should call 1-800-695-8544). You may also submit your request faxing it to 1-877-533-2402 or in writing to:
Fidelis Care New York
Member Services Department
95-25 Queens Boulevard
Rego Park, NY 11374
Be sure to include the following:
- Your Name, Address and Telephone Number
- Your 9 digit Fidelis Care Member Identification Number
- The date of the incident(s), the parties involved, the reason for your grievance, organization determination or appeal.
All non-urgent requests will be acknowledged in writing. For grievances you should receive a response within 30 calendar days.
For all organization determination requests or payment appeals you will receive a written response within 60 calendar days. Any organization determination or appeal that is not found in your favor will automatically forwarded to the IRE for another level of review.
If you have any questions on the process or the status of your requests please call our Member Services Department at 1-800-247-1447, TTY users should call 1-800-695-8544. From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week. From February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
In order to receive a report on the number of grievances or appeals that are filed with the plan you can place your request in writing by fax or to the address above.
Extensions: This time period may be extended by up to 14 days if the member asks for such an extension or if Fidelis Care can prove the need to extend the time frame.
Late Filing After 60 days of the Incident-Good Cause Conditions Upon Which a Plan May Grant a Good Cause for Late Filing Exception: If you submit good cause for your late filing in writing Fidelis Care may extend the time frame for filing a request for reconsideration.
Expedited Organization Determination: An enrollee, or any physician (regardless of whether the physician is affiliated with the Fidelis care), may request an expedited organization determination when you or your physician believes that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy.
Expedited organization determinations may not be requested for cases in which the only issue involves a claim for payment for services that the enrollee has already received. However, if a case includes both a payment denial and a pre-service denial, the enrollee has a right to request an expedited appeal for the pre-service denial.
How to File an Expedited Organization Determination: When asking for an expedited organization determination, the enrollee or a physician must submit either an oral or written request directly to Fidelis Care by calling our Member Services Department, Faxing to Member Services Department or if applicable, to the entity responsible for making the determination. A physician may also provide oral or written support for an enrollee’s own request for an expedited determination.
If Fidelis Care decides to expedite the request, we must render a decision as expeditiously as the enrollee’s health condition might require, but no later than 72 hours after receiving the enrollee’s request; and if the plan denies the expedited request it must automatically transfer the request to the standard time frame and make a determination within 14 calendar days from the date the request.
How to file an Expedited Appeal: Your, Your Physician or Authorized Representative should call or fax Member Services.
If Fidelis Care approves your request for an expedited reconsideration, then we must complete the expedited reconsideration and give you, and the physician involved notice of its reconsideration as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request.
If Fidelis Care denies a request for an expedited reconsideration, it must automatically transfer the request to the standard reconsideration process and then make its determination as expeditiously as the enrollee’s health condition requires, but no later than within 30 calendar days from the date the Medicare health plan received the request for expedited reconsideration.
Standard Pre-Service Reconsiderations: This occurs when your or your doctor may submit a request for an authorization or request for services are denied before the services are rendered. You can call our Member Services Department or by fax to: 716-393-6779.
How to file an Expedited Grievance: An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. Your, Your Physician or Authorized Representative should call or fax Member Services.
Appointment of Representative Form
Medicare Part D Information:
You also have the right to contact us to request a coverage determination. When Fidelis Care makes a coverage determination, we are making a decision about whether or not to provide or pay for a Part D drug and what your share of the cost will be. Coverage determinations include exception requests. (Follow the link below.) If you would like to ask us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what your share of the cost will be, you have the right to file an appeal. Please follow the Appeals & Grievances link below to find more detailed information. You can refer to Chapter 7 of the Fidelis Medicare Advantage without RX Evidence of Coverage document and Chapter 9 of all other Evidence of Coverage documents.
Request for Redetermination of Medicare Prescription Drug Denial (.pdf).
The following medication request form must be completed and submitted when your physician is requesting an exception to our Medicare Part D Formulary:
For more information on appeals, please review the "Appeals" section of your Evidence of Coverage document (you can find the Evidence of Coverage documents by selecting your Medicare product here).
To obtain an aggregate number of grievances, appeals and exceptions filed with the Plan you can contact our Member Services department at 1-800-247-1447 (TTY: 1-800-695-8544).
Questions? Call our Member Services Department at 1-800-247-1447 (TTY: 1-800-695-8544). From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week and from February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.
(Updated 10/12/2016) H3328_FC 16153 Approved