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Organization Determinations, Grievances & Appeals

Organization Determination | Member Appeals | Member Grievances

Organization Determination

What is an Organization Determination?

An organization determination is SWH’s initial decision about whether we will provide the medical care or service you request, or pay for a service you have received.

Who can ask for an Organization Determination?

An organization determination may be requested by you, your doctor or your appointed representative.

What to do if you have complaints

SWH is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to SWH. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.

There are two types of formal complaints you can make. They are appeals and grievances.

Member Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

You may file an appeal.
OR
Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:

Provide SWH with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a provider, a family member or friend, etc.)

For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Senior Whole Health Plus of NY HMO and/or CMS regarding the denial or discontinuation of medical services."
You must sign and date the statement.
Your representative must also sign and date this statement.
You must include this signed statement with your appeal.

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (organization determination) that was made regarding a service, or the amount of payment SWH pays or will pay for a service, or the amount you must pay for a service.

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

SWH refuses to cover or pay for services you think SWH should cover.
SWH or one of the contracting medical providers refuses to give you a service you think should be covered.
SWH or one of the contracting medical providers reduces or cuts back on services you have been receiving.
If you think that SWH is stopping your coverage too soon.

Note: The sixty- (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty- (60) day time frame.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us or by contacting Member Services at the telephone number (or the TTY number for the hearing impaired) listed below. You may also contact Member Services and request the facsimile number for appeals and grievances.

Member Services: Our hours of operation are weekdays, Monday through Friday, from 8AM to 8PM, and also on Saturdays and Sundays from November 15th to March 1st. Someone is available, however, 24-hours a day, if assistance is needed. Interpreter services are available upon request.

1-866-211-1777 (toll-free)
1-866-404-9507 (TTY)

When will a Decision be made?

We must give you a response no later than 7 calendar days after we receive your appeal. If you need a faster decision (called an expedited appeal), contact Member Services at the telephone number (or the TTY number for the hearing impaired) listed in the paragraph above.

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment SWH paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "time-sensitive" situations. A time-sensitive situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize:

your life or health, or
your ability to regain maximum function.

If SWH or your Primary Care Physician, decides, based on medical criteria, that your situation is time-sensitive or if your covering PCP or Specialist calls or writes in support of your request for an expedited review, SWH or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

Member Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

You may file a grievance.
OR
Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:

Provide SWH with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a provider, a family member or friend, etc.)

For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Senior Whole Health Plus of NY HMO and/or CMS regarding the denial or discontinuation of medical services."
You must sign and date the statement.
Your representative must also sign and date this statement.
You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make about a problem that does not involve payment or services by SWH or a contracting medical provider. For example, you would file a grievance:

If you have a problem with things such as the quality of your care during a hospital stay
If you feel you are being encouraged to leave your plan
When you feel waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room are too long
When you feel you are waiting too long for prescriptions to be filled
If you are dissatisfied with the way your doctors, network pharmacists or others behave
When you are unable to reach someone by phone or obtain the information you need.

When can a Grievance be filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care.

Note: The sixty- (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty- (60) day time frame.

Expedited Grievance

You have the right to request a fast review or expedited grievance if you disagree with SWH’s decision to invoke an extension on your request for an organization determination or reconsideration, or SWH’s decision to process your expedited request as a standard request. In such cases, SWH will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of SWH’s conclusion within three (3) calendar days.

Where can a Grievance be filed?

A grievance may be filed in writing directly to us or by contacting Member Services at the telephone number (or the TTY number for the hearing impaired) listed below. You may also contact Member Services and request the facsimile number for appeals and grievances.

1-866-211-1777 (toll-free)
1-866-404-9507 (TTY)

When will a Decision be made?

We must give you a decision no later than 30 calendar days after we receive your grievance. If you would like to inquire about the status of a grievance, please call Member Services toll-free at the number listed on your identification card.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with SWH or a contracting medical provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Last modified: 04/01/2010