SelectHealth grievance and appeals

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Service Authorization Requests are requests made by a member, or a provider on the member’s behalf to the plan to provide a service, including a request for a referral or for a non-covered service.

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.

Concurrent Review Request is a Service Authorization request by a member, or a provider on the member’s behalf to continue or request more of a service the health plan is currently authorizing.

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.

Expedited Prior Authorization Request will be decided within 72 hours from receipt of request for services.

Requests for home health care services following an inpatient admission, Monday through Thursday excluding holidays 1 business day after all information is received, but no more than 72 hours; if the next day is a Friday or a holiday within 72 hours of receipt.

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

Expedited Concurrent Review Request will be decided within 1 business day after all information is received but no more than 72 hours from receipt of the request.

Timeframes for Service Authorizations determinations may be extended for up to 14 calendar days if the member, the member’s designee, or the member’s provider requests an extension orally or in writing; or if the plan can demonstrate a need for additional information and how the extension is in the member’s interest.

Timeframes for Reducing, Suspending, or Terminating Existing Services

When the plan intends to a previously authorized service within an authorization period, it must provide the member with a written notice at least 10 days prior to the intended Action, except when the period of advance notice is shortened to 5 days in cases of confirmed member fraud.

An appeal is filed when the member wants us to reconsider or change a plan decision. Members may designate a representative to file Appeals on his or her behalf. 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 refuse 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.

An appeal may be filed by the member or his or her designee orally or in writing. Appeals must be requested no less than 60 calendar days of the date on the Initial Adverse Determination. Oral Appeals must be followed by a written, signed Appeal sent to the plan.

Expedited Appeals are conducted when the plan or the provider feels that a delay would seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function, or when the adverse determination involved a Concurrent Review Request. The plan will resolve expedited Appeals as fast as the member’s condition requires, within 72 hours of receipt of the Appeal.

If the plan denies the member an expedited appeal, the plan will handle the request under the standard appeal request timeframes. The plan will notify the member of the denial for an expedited appeal orally and send a written notice within 2 days of the determination.

For standard Appeals the plan will send a written acknowledgment of the Appeal within 15 days of receipt. If the determination is reached before the acknowledgment is sent, the plan may include the written acknowledgment with the notice of Appeal determination (one decision). The plan will resolve Appeals as fast as the member’s condition requires and no more than 30 days from the date of the receipt of the Appeal.

Enrollees 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 makes a decision 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 makes a determination 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.

To file an appeal, write to:

VNS Health
Health Plans – Grievance & Appeals
PO Box 445,
Elmsford, NY 10523

You can also call the SelectHealth Care Team at 1-866-469-7774 (TTY: 711), 8 am to 6 pm, Monday – Friday, if you need help filing an appeal. Interpreter services are also available.

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.

If the Plan denies a member’s request to file an expedited appeal, it will process the request under the standard timeframe and make a determination within 30 calendar day. 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 days of receiving the request.

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 Administrative Hearings (OAH) if the Plan’s decision about an appeal is not in the member’s favor. OAH will issue a written decision to either uphold or reverse the plan’s decision. However, the State of New York requires that member exhaust the plan’s internal appeal process before a fair hearing is requested. A Fair Hearing must be filed within 120 days from the date of the plan’s Final Adverse Determination notice.

If an appeal is denied because it is determined that the service is not medically necessary or are experimental or investigational, members have the right to file an external appeal within 4 months of the notice of appeal decision. If a member requests both a State Fair Hearing and external appeal, the decision of the Fair Hearing Officer is the final decision. A member is eligible for an external appeal when the member has exhausted the plan’s internal utilization review procedure, has received a final adverse determination from the plan, or the member and the plan have agreed to waive internal appeal procedures.

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 your doctor’s office, whether that is its condition or cleanliness, or you are kept too long in the waiting room.

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.

To file a complaint, write to:

VNS Health
Health Plans – Grievance & Appeals
PO Box 445,
Elmsford, NY 10523

You can call the SelectHealth Care Team at 1-866-469-7774 (TTY: 711), 8 am to 6 pm, Monday – Friday, if you need help filing a complaint. Interpreter services are also available.