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1-877-353-0188 (Toll-free)
TTY/TDD 711
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1-877-353-0185 (Toll-free) 
TTY/TDD 711

Organizational Decisions & Appeals


Organizational Decision

What is an organizational decision?

An organizational decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We are making an organizational decision whenever we decide what is covered for you and how much we pay.

Who can request an organization determination?

You, your doctor, or someone else you appoint may request it on your behalf. You may appoint an individual to act as your representative by filling out a personal representative authorization form. (To get the form, call Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website.*)
* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

How to request an organizational decision for the medical care you want.

You may file your request orally or in writing.

  • CALL:    
    • 1-877-353-0185 (TTY/TDD 711), calls to this number are free
  • FAX:      
    • 1-855-818-4871
  • WRITE:
    • Senior Whole Health of New York  
      Attention: Quality Manager  
      Church St. Station
      PO Box 1624   
      New York, New York 10008-1624           

How long will it take to get a decision?

When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard organizational decision means we will give you an answer within 14 days after we receive your request.

A fast organizational decision means we will answer within 72 hours.
  • To get a fast organizational decision, you must meet two requirements: If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast organizational decision.
    • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If you ask for a fast decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care/drug coverage you want.

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Appeals

What is an appeal?

If we make an organizational 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 an organizational decision we have made.

Who can file an appeal?

You may file an appeal, someone else may file the appeal on your behalf, or your doctor may file an appeal. You may appoint an individual to act as your representative to file an appeal for you by filling out a personal representative authorization form. (CMS- 1696)

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 Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website.*)

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

When can an Appeal be filed?

The request must be made within 60 days of receiving the coverage decision.

How to request an appeal for the medical care you want.

You may file your request orally or in writing.
  • CALL:    
    • 1-877-353-0185 (TTY/TDD 711), calls to this number are free
  • FAX:      
    • 1-855-818-4871
  • WRITE:
    • Senior Whole Health of New York  
      Attention: Quality Manager  
      Church St. Station
      PO Box 1624   
      New York, New York 10008-1624  

How long will it take to get an appeal decision?

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.

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. The requirements and procedures for getting a "fast appeal" are the same as those for getting a fast organizational decision (see above). If your doctor tells us that your health requires a "fast appeal," we will give you a fast appeal.

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What happens next?

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 another review.

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Do I have any other options?

Fair Hearings

In some cases, you may have the right to request a Fair Hearing from the New York State Office of Temporary and Disability Assistance (ODTA) at the same time as filing an appeal with the plan. We will tell you in writing when we make our decision whether you have the right to request a Fair Hearing.

When can a Fair Hearing be filed?

If you are eligible to file a Fair Hearing request, you must do so within 60 days of being notified of decision that you are unhappy with.

How do I request a Fair Hearing?

To request a Fair Hearing, you or your authorized representative must file a Fair Hearing Request Form with the OTDA. You can use one of the following ways to request a Fair Hearing:

  • CALL:    1-800-342-3334
  • FAX:      518-473-6735
  • WRITE:  Fair Hearing Section
                NYS Office of Temporary and Disability Assistance
                P.O. Box 22023
                Albany, New York 12201
  • INTERNET: www.otda.state.ny.us/oah/forms.asp *
  • WALK-IN: Bring a copy of all pages of Termination, Reduction Suspension or Denial of Benefits Notice to the Office of Administrative Hearings, of the Office of Temporary & Disability Assistance, 3330 West 34th Street, 3rd floor, New York, N.Y. –or– 14 Boerum Place, 1st floor, Brooklyn, New York.
After receiving your request, OTDA will schedule a fair hearing as soon as possible.

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

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Additional Resources

Medicaid External Appeals

In some cases, you may also have the right to ask New York State for an independent external appeal. This is called an external appeal because it is decided by reviewers who do not work for the health plan or for the state. These reviewers are qualified people approved by New York State. The service must be in the plan's benefit package or be an experimental treatment, clinical trial, or treatment for a rare disease.

We will tell you in writing when we make our decision whether you have the right to request an External Appeal.

When can an Eternal Appeal be filed?

You have 4 months after you receive the plan's final adverse determination to ask for an external appeal.

How do I request an External Appeal?

To ask for an external appeal, fill out an application and send it to the Department of Financial Services. You can call Member Services if you need help filing an appeal. Here are some ways to get an application:

  • Call the Department of Financial Services, 1-800-400-8882
  • Go to the Department of Financial Services' website at www.dfs.ny.gov *
  • Contact Senior Whole Health of New York at 1-877-353-0185 (TTY/TDD 711)
* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

How long will it take to get an External Appeal decision?

Standard External Appeals will be decided in 30 days. You and the plan will be told the final decision within two days after the decision is made.

You can get a faster decision if your doctor says that a delay will cause serious harm to your health. Then external appeal reviewer must make a decision on a fast external appeal in 72 hours or less. The reviewer will tell you and the plan the decision right away by phone or fax. Later, a letter will be sent that tells you the decision.

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You can file an External Appeal and a Fair Hearing at the same time.

If you ask for a fair hearing and an external appeal, the decision of the fair hearing officer will be the one that counts.

For more information please refer to your Medicaid Handbook and Evidence of Coverage.

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If you or your physician have status or process questions please call Member Services at 1-877-353-0185 (TTY/TDD users, please call 711) from 8 a.m. to 8 p.m., seven days a week. You may also request information on the aggregate number of grievances, appeals, and exceptions filed with the plan.

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You have a right to file a complaint with Medicare and the State of New York at any time, for any reason.

Medicaid

You, or someone you trust, have the right to file a complaint at anytime with the New York State Department of Health by calling 1-888-712-7197. You have the right to be represented by an attorney.

Medicare

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form linked to here.

Medicare Complaint Form

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.

The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048.


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You may contact The Medicare Beneficiary Ombudsman

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. For more information about The OMO, click here.*

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website. 

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Last Updated 01/08/2018
H5992_2014_109 Approved 01/13/2014