SelectHealth Grievance and Appeals
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, for home health care services following an inpatient admission or for continued, extended or more of an authorized service that what is currently authorized by the plan.
Request for home health care services following an inpatient admission, 1 business day after receipt of necessary information; except when the day subsequent to the Service Authorization Request falls on a weekend or holiday, 72 hours after receipt of necessary information; but no more than 3 business days after receipt of the Service Authorization 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.
Expedited Prior Authorization Request will be decided within 3 business day of receipt of request for services.
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 Concurrent Review Request will be decided within 1 business day of receipt of all necessary information but no more than 3 business days of receipt of request for services.
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.
Timeframes for Notice of Actions Other than Service Authorizations
When the plan intends to reduce, suspend, or terminate 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.
FILING AN ACTION APPEAL
An action appeal is filed when the member wants us to reconsider or change a plan decision. Members may designate a representative to file Complaints, Complaint Appeals and Action Appeals on his or her behalf. For example, you could file an action 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 action appeal may be filed by the member or his or her designee orally or in writing. Action Appeals must be requested no less than 60 business days and no more than ninety (90) days from the date of the notice of action to file an Action Appeal. Oral Action Appeals must be followed by a written, signed Action Appeal sent to the plan.
Expedited Action 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 action involved a Concurrent Review Request. The plan will resolve expedited Action Appeals as fast as the member’s condition requires, within 2 business days of receipt of necessary information and no later than 3 business days of the date of the receipt of the Action Appeal.
If the plan denies the member an expedited action appeal, the plan will handle the request under the standard action appeal request timeframes. The plan will notify the member of the denial for an expedited action appeal orally and send a written notice within 2 days of the determination.
For standard Action Appeals the plan will send a written acknowledgement of the Action Appeal within 15 days of receipt. If the determination is reached before the acknowledgement is sent, the plan may include the written acknowledgment with the notice of Action Appeal determination (one decision). The plan will resolve Action Appeals as fast as the member’s condition requires and no more than 30 days from the date of the receipt of the Action Appeal.
Aid to Continue while appealing a decision about your care:
If an action involves the termination, suspension or reduction of a previously authorized service and the enrollee files an action appeal within ten (10) days of the action notice or by the intended date of an action, whichever is later, the enrollee may request aid to continue.
To file an action appeal, write to:
Select Health Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523
You can also call Member Services at 1-866-469-7774, Monday – Friday, 8 am – 6 pm (TTY/TDD users, please call 711), if you need help filing an action appeal. Interpreter services are also available.
WHAT IS THE DIFFERENCE BETWEEN A "STANDARD" AND AN "EXPEDITED" ACTION APPEAL FOR MEDICAL CARE?
If you or your provider feels that taking the time for a standard action appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the action. We will respond to you within 2 business days after we receive all necessary information but no later than 3 business days 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. 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.
WHAT IF A MEMBER’S REQUEST FOR AN EXPEDITED REVIEW IS DENIED?
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.
WHAT IS A STATE FAIR HEARING?
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. Members may seek redress of adverse determinations simultaneously through the plan’s internal process and the State Fair Hearing process. A member may also seek a fair hearing for the plan’s failure to act with reasonable promptness with respect to such services.
WHAT IS AN EXTERNAL APPEAL?
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.
FILING A COMPLAINT
A “Complaint” is an expression of dissatisfaction with any matter other than a “Plan Action” 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.
Expedited and Standard Complaint and Complaint Appeal
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 which can be submitted by letter or on a form supplied by the Plan. 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 grievance write to:
Select Health Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523
You can call Member Services at 1-866-469-7774, Monday – Friday, 8 am – 6 pm (TTY/TDD users please call 711), if you need help filing a complaint. Interpreter services are also available.