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FIDA Grievances & Appeals

What is a Grievance?

A grievance is a written or spoken statement saying that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies.”  “Filing a grievance” is another way of saying “making a complaint.” The grievance process is used for certain types of problems only, such as problems related to quality of care, waiting times, and customer service.  Some examples of grievances are:

  • Grievances about quality
    • You are unhappy with the quality of care, such as the care you got in the hospital.
  • Grievances about privacy
    • You think that someone did not respect your right to privacy, or shared information about you that is confidential
  • Grievances about poor customer service
    • A health care provider or staff was rude or disrespectful to you.
    • Centers Plan for FIDA Care Complete staff treated you poorly.
    • You think you are being pushed out of the plan.
  • Grievances about accessibility
    • You cannot physically access the health care services and facilities in a provider’s office.
    • Your provider does not give you a reasonable accommodation you need such as an American Sign Language interpreter.
  • Grievances about waiting times
    • You are having trouble getting an appointment, or waiting too long to get it.
    • You have been kept waiting too long by providers, pharmacists, or other health professionals or by Participant Services or other plan staff.

Please see Chapter 9, Section 10 of the Participant Handbook for more examples and additional information on grievances.

Internal Grievances

To file an internal grievance, call Participant Services at 1-800-466-2745 (TTY users call 1-800-421-1220 or 711).  The grievance must be made within 60 calendar days after you had the problem you want to complain about.

  • If there is anything else you need to do, Participant Services will tell you.
  • You can also write your grievance and send it to us. If you put your grievance in writing, we will respond to your grievance in writing.

Most grievances are answered in 30 calendar days. If possible, we will answer you right away. If you call us with a grievance, 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.

  • If you need a response faster because of your health, we will give you an answer within 48 hours after we get all necessary information (but no more than 7 calendar days from the receipt of your grievance).
  • If you are filing a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will respond to your grievance within 24 hours.
  • If you are filing a grievance because we took extra time to make a coverage decision, we will respond to your grievance within 24 hours.

If we do not agree with some or all of your grievance, we will tell you and give you our reasons. We will respond whether we agree with the grievance or not. If you disagree with our decision, you can file an external grievance.

External Grievances

You can tell Medicare about your grievance You can send your grievance (complaint) to Medicare. The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.

Your grievance will be sent to the Medicare and Medicaid team overseeing Centers Plan for FIDA Care Complete and the FIDA Program.

You can tell the New York State Department of Health about your grievance To file a grievance with the New York State Department of Health (NYSDOH), call the NYSDOH Helpline at 1-866-712-7197.  Your grievance will be sent to the Medicare and Medicaid team overseeing Centers Plan for FIDA Care Complete and the FIDA Program. You can file grievances about disability access or language assistance with the Office of Civil Rights If you have a grievance about disability access or about language assistance, you can file a grievance with the Office of Civil Rights at the Department of Health and Human Services. Linda Colon, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services Jacob Javits Federal Building 26 Federal Plaza – Suite 3312 New York, NY 10278 Voice Phone: 1-800-368-1019 FAX: 1-212-264-3039 TDD/TTY: 1-800-537-7697 You may also have rights under the Americans with Disability Act and under applicable state law. You can contact the Independent Consumer Advocacy Network (ICAN) for assistance.

You can file grievances about quality of care to the Quality Improvement Organization When your grievance is about quality of care, you also have two choices:

  • If you prefer, you can make your grievance about the quality of care directly to the Quality Improvement Organization (without making the grievance to us).
  • Or you can make your grievance to us and also to the Quality Improvement Organization. If you make a grievance to this organization, we will work with them to resolve your grievance.

The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. The phone number for the Quality Improvement Organization is 1-866-815-5440.

Medicare Complaint Form
You are able to provide feedback directly to Medicare through their Complaint Form.   The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.

How & who may file a Grievance

  • As a Centers Plan for FIDA Care Complete Participant, you may file a grievance in either written or oral form
  • You may appoint someone to file a grievance on your behalf. Please see the “How to Appoint a Representative” section on this page.
  • You can file a grievance by email: GandA@centersplan.com
  • You may file a grievance by fax: 1-347-505-7089
  • You may file a grievance by mail:

Centers Plan for FIDA Care Complete
75 Vanderbilt Avenue,
Staten Island, NY 10304
Attention: Grievance and Appeals Department

(Please be sure to provide your name, Medicare number and the nature of your complaint; and remember to sign and date your grievance.)

You may file a grievance by contacting Participant Services at 1-800-466-2745 (or TTY number 1-800-421-1220) 7 days a week, 8am-8pm.

Centers Plan for FIDA Care Complete will send you a letter within 15 days to acknowledge we received your complaint. If your complaint is resolved in less than 15 days, Centers Plan for FIDA Care Complete will send you a resolution letter describing how we resolved your complaint.

What is an Appeal

An appeal is a formal way of asking us to review a decision made by your IDT, Centers Plan for FIDA Care Complete, or an authorized specialist and change it if you think a mistake was made. For example, your IDT, Centers Plan for FIDA Care Complete, or an authorized specialist might decide that a service, item, or drug that you want is not covered. If you or your provider disagree with that decision, you can appeal.

There are two Levels of Appeal.

A Level 1 Appeal is the first appeal to Centers Plan for FIDA Care Complete. Centers Plan for FIDA Care Complete will review your coverage decision to see if it is correct. The reviewer will be someone at Centers Plan for FIDA Care Complete who is not part of your Interdisciplinary Team (IDT) and was not involved in the original coverage decision. When we complete the review, we will give you our decision in writing. If you need a fast decision because of your health, we will also try to notify you by phone. If we do not decide the Level 1 Appeal in your favor, we will automatically forward your appeal to the Integrated Administrative Hearing Office (IAHO) for a Level 2 Appeal.

How and who can file a Level 1 Appeal?

You or your provider can make the appeal on your behalf. Also, you may appoint a representative to make the appeal on your behalf by following the instructions in the section below titled “How to Appoint a Representative”. There are several ways to file an appeal:

  • Contacting Participant Services at 1-800-466-2745 (or TTY number 1-800-421-1220) 7 days a week, 8am-8pm
  • Emailing us at : GandA@centersplan.com
  • Faxing the Appeal to us at: 1-347-505-7089
  • Mailing the Appeal to us at :

Centers Plan for FIDA Care Complete
75 Vanderbilt Avenue,
Staten Island, NY 10304
Attention: Grievance and Appeals Department

Appeal Time Frame You will have sixty (60) calendar days from the date on the notice sent to you regarding the action taken by Centers Plan for FIDA Care Complete to file an appeal. If you want services to continue while the appeal is being reviewed, you must request the appeal as “aid continuing” within 10 days of the date we sent you the notice or the effective date of the action. The appeal may be made verbally or in writing. The sixty (60) day may be extended if a good cause reason is provided. Centers Plan for FIDA Care Complete will send you a letter within 15 days to acknowledge we received your appeal. We will resolve your Appeal within the following time frame:

  • Standard: Standard Appeals will be decided within thirty (30) calendar days from receipt of the appeal.
  • Expedited: When a delay would significantly increase the risk to your health, a decision will be made within 72 hours (3 days) of the receipt of the appeal.
  • Extension: We may request up to 14 additional days to review your appeal if we need more information and the delay is in your best interest. We will notify you in advance if we require an extension.


How to Appoint a Representative You can ask us for a coverage determination or an appeal for yourself, or your prescribing physician or someone you name may do it for you. You may also choose another person to file a grievance or appeal on your behalf. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date an Appointment of Representative Form:

  • English Appointment of Representative Form – Click here
  • Spanish Appointment of Representative Form – Click here

This form must be sent to us at:

Centers Plan for FIDA Care Complete
Grievances and Appeals Department
75 Vanderbilt Avenue,
Staten Island, NY 10304

You may also fax the form to us at: 1-347-505-1089 Or email it to us at: GandA@centersplan.com You can call us at 1-800-466-2745, 7 days a week, 8AM-8PM, (TTY users please call 1-800-421-1220), to learn how to name your appointed representative. You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Grievance, Appeals & Exception Reporting

You are entitled to obtain a report about the number of grievances, appeals and exceptions that have been filed with Centers Plan for FIDA Care Complete. For more information, contact Participant Services at 1-800-466-2745, (TTY users please call 1-800-421-1220 or 711), 8 am–8 pm, 7 days a week.

How to inquire about the status of your Grievance or Appeal

If you have questions about the Grievance and Appeals process, or want to know the status of your Grievance or Appeal, please call Participant Services at 1-800-466-2745 (TTY users please call 1-800-421-1220 or 711).

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 Centers Plan for FIDA Care Complete. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org. (TTY users call 711 then follow the prompts to dial 844-614-8800).

Centers Plan for FIDA Care Complete Disclaimers

Centers Plan FIDA Care Complete (Medicare-Medicaid Plan) is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

 


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Last modified: Apr 4, 2019