How can I join?
Call the New York Enrollment Broker:
1-855-600-FIDA (Toll-free)
TTY/TDD 1-888-329-1541
Participant Services:
1-844-861-FIDA (3432), TTY/TDD: 711

Organizational Decisions & Appeals

Organization Determinations

What is an organization determination?

An organization determination 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 organization determination 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 Participant 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 SWH Whole Health FIDA Plan website.

How to request an organization determination for the medical care you want.

You may file your request orally or in writing.
  • CALL:    
    • 1-844-861-FIDA (3432), TTY/TDD: 711, calls to this number are free
      We are open 8 a.m. - 8 p.m., seven (7) days a week.
  • FAX:      
    • 1-855-818-4871
  • WRITE:
    • SWH Whole Health FIDA Plan  
      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 organization determination means we will give you an answer within 14 days after we receive your request.

A fast organization determination means we will answer within 72 hours.
  • To get a fast organization determination, 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 organization determination.
    • 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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Medical/Clinical Appeals

What is an appeal?

If we make an organization determination 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 organization determination 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 Participant 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 SWH Whole Health FIDA Plan website.

When can an Appeal be filed?

The request must be made within 60 days of receiving the coverage decision. If there is no request to continue benefits while the Appeal decision is pending. If the Appeal involves the termination or modification of a previously authorized service and the Appeal is filed within ten (10) calendar days of the notice's postmark or by the intended effective date of the Action, the Participant shall continue to receive benefits while the Appeal decision is pending.

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

You may file your request orally or in writing.

  • CALL:    
    • 1-844-861-FIDA (3432), TTY/TDD: 711, calls to this number are free
      We are open 8 a.m. - 8 p.m., seven (7) days a week.
  • FAX:      
    • 1-855-838-7998
  • WRITE:
    • SWH Whole Health FIDA Plan
      58 Charles Street
      Cambridge, MA 02141

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 organization determination (see above). If your doctor tells us that your health requires a "fast appeal," we will give you a fast appeal.

Extension

An extension may be requested by a Participant or provider on a Participant's behalf (written or oral). SWH Whole Health FIDA Plan may also initiate an extension if it can justify need for additional information and if the extension is in the Participant's interest.

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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 Integrated Administrative Hearing Office at the FIDA Administration Hearing Unit at the State Office of Temporary and Disability Assistance (OTDA) for another review.

SWH Whole Health FIDA Plan will send an Acknowledgement of Automatic Administrative Hearing and Confirmation of Aid Status if requested within fourteen (14) calendar days of forwarding the administrative record with a copy to the Integrated Administrative Hearing Office. If a decision is reached before the written acknowledgement is sent, SWH Whole Health FIDA Plan will not send the written acknowledgement.

The Integrated Administrative Hearing Office shall provide you and SWH Whole Health FIDA Plan with a Notice of Administrative Hearing at least ten (10) calendar days in advance of the hearing date.

The Integrated Administrative Hearing Office shall create the administrative record at the second level of Appeal and allow for requesting and receiving copies of the administrative record.

The Integrated Administrative Hearing Office shall issue a written decision that explains in plain language the rationale for the decision and specifies the next steps in the Appeals process, including where to file the Appeals, the filing time frames, and other information required by applicable Federal and State requirements.

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Do I have any other options?

Medicare Appeals Council

If a participant disagrees with the Integrated Administrative Hearing Officer's decision, the participant may appeal that decision further to the Medicare Appeals Council, which may overturn the Integrated Administrative Hearing Office's decision. The Medicare Appeals Council will apply all Medicare and Medicaid coverage rules. 

The participant submits his/her request for Medicare Appeals Council review to the Integrated Administrative Hearing Office. This must be done within sixty (60) calendar days of the date of the adverse decision by the Integrated Administrative Hearing Office. The Integrated Administrative Hearing Office will forward the Appeal and the record to the Medicare Appeals Council. These Appeals must be filed with the FIDA Administrative Hearing Unit, which will forward the request for Appeal and administrative record to the Medicare Appeals Council. The Medicare Appeals Council will complete a paper review and will issue a decision within ninety (90) calendar days from the receipt of the appeal request. Benefits will continue pending an Appeal.

Federal District Court

An adverse Medicare Appeals Council decision may be appealed to the Federal District Court, which serves as the fourth level of Appeal.

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Additional Resources


If you or your physician have status or process questions please call Participant Services at 1-844-861-FIDA (3432) (TTY/TDD users, please call 711) from 8 a.m. to 8 p.m., seven (7) 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 SWH Whole Health FIDA Plan 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 can get help from the Independent Consumer Advocacy Network (ICAN)

If you need help getting started, you can always call ICAN. ICAN can answer your questions and help you understand what to do to handle your problem. ICAN is not connected with SWH Whole Health FIDA Plan or with any insurance company or health plan. ICAN can help you understand your rights and how to share your concerns or disagreement with us. The toll-free number for ICAN is 1-844-614-8800. The services are free.

Participant Ombudsman (PO) Contact Information:

Independent Consumer Advocacy Network (ICAN)
Call: 1-844-614-8800
A free interpreter: 1-844-614-8800
TTY: 711
Monday - Friday, 8:00 a.m. - 8 p.m.
Online: icannys.org*

* Please note: By clicking on this link you will be leaving the SWH Whole Health FIDA Plan website.

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Last Updated 10/27/2015
H8851_2016_099 Approved 12/15/2015