CompleteCare (HMO D-SNP) - Member Handbook - Healthfirst
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CompleteCare (HMO D-SNP)
Member Handbook
This handbook will tell you how to use your Healthfirst plan.
Keep this handbook where you can find it when you need it.
January 1–December 31, 2022
New York: Bronx, Kings, Nassau, New York, Orange, Queens,
Richmond, Rockland, Sullivan and Westchester Counties
H3359_MSD22_28 1066-21_C
Important Phone Numbers
HEALTHFIRST CORPORATE OFFICE: 100 Church Street, New York, NY 10007
• change your PCP
• with questions about benefits and services 1-888-260-1010
Member Services • replace an ID card (TTY 1-888-542-3821)
can help you: • report a birth 8am–8pm, 7 days a week, Oct. to
• with referrals Mar; Mon. to Fri., Apr. to Sept.
• enroll in a medical management program
HEALTHFIRST NETWORK PROVIDERS
• select a primary care dentist 1-800-508-2047
Dental • inquire about services covered
Monday to Friday, 8am–8pm
• find a dentist’s location
• inquire about benefit coverage 1-800-753-3311
Monday to Friday, 8am–11pm
Vision • locate participating eye doctors
Saturday, 9am–4pm
(optometrists and opticians) Sunday, 12pm–4pm
NationsHearing • schedule hearing exams 1-877-438-7251
Hearing • get help purchasing hearing aids Monday to Friday, 8am–8pm
1-888-260-1010
• submit a pharmacy claim
Pharmacy • inquire about drug coverage and
(TTY 1-888-542-3821)
Prescriptions prescription-related issues 8am–8pm, 7 days a week, Oct. to
Mar; Mon. to Fri., Apr. to Sept.
GOVERNMENT OFFICES
1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048)
Medicare 24 hours a day, 7 days a week
Elderly Pharmaceutical 1-800-332-3742 (TTY 1-800-290-9138)
Insurance Coverage Program Monday to Friday, 8am–5pm
Local Department of Social Services (Please Fill In)
Use this space to fill out you and your family’s provider information.
Member Name: PCP Name:
Phone Number:
Address:
Member Name: PCP Name:
Phone Number:
Address:
Member Name: PCP Name:
Phone Number:
Address:
IMPORTANT COMPLETECARE PHONE NUMBERS
1-888-260-1010 (TTY 1-888-542-3821)
Member Services 8am–8pm, 7 days a week, Oct. to Mar;
Mon. to Fri., Apr. to Sept.
New York State Health Dept. (Complaints) 1-866-712-7197
New York City - Human Resources Administration (HRA)
1- 888-692-6116 or 1-718-557-1399
Medicaid Helpline
Nassau - Medicaid 1-516-227-8000
Orange - Medicaid 1-845-291-4000
H3359_MSD21_13 1555-20_C1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org i1IMPORTANT COMPLETECARE PHONE NUMBERS
Rockland - Medicaid Unit 1-845-364-3040
TABLE OF
Sullivan - Medicaid 1-845-292-0100 or 1-845-292-5910 CONTENTS
Westchester - General Information/Case Management
1-914-995-5000 or 1-914-995-3333
Information Center (CMIC) Important Phone Numbers. . . . . . . . . . . . . . . . . . i Services not covered by the plan or
by Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
New York Medicaid CHOICE (For Long-Term Care Information) 1-888-401-6582 (TTY 1-888-329-1541) Welcome to Healthfirst CompleteCare
(HMO D-SNP) Medicaid Advantage Plus Plan. . . 2 How do I get approval for treatments or
New York Medicaid CHOICE (All Other Reasons) 1-800-505-5678 (TTY 1-888-329-1541) services?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Membership Card. . . . . . . . . . . . . . . . . . . . . . . . . 2
The Health Insurance Information Service Authorization Request (also known
1-800-701-0501
Counseling and Assistance Program (HIICAP) Help from Member Services. . . . . . . . . . . . . . . . 2 as Coverage Decision Request). . . . . . . . . . . 15
For medical emergencies, please call 911, or go to the nearest emergency room, an urgent care center, or a Who is eligible for enrollment in Healthfirst Which services require prior authorization?. 15
medical center. You will be asked to present your Healthfirst Member ID card when you receive emergency care. CompleteCare Medicaid Advantage Plus Plan?.2
What happens after we get your service
What is the enrollment process for Healthfirst authorization request. . . . . . . . . . . . . . . . . . . . 16
CompleteCare Medicaid Advantage Plus?. . . . . 3
If we are changing a service you are
Withdrawal of Enrollment .. . . . . . . . . . . . . . . . 4 already getting . . . . . . . . . . . . . . . . . . . . . . . . . 16
What are my rights and responsibilities as What To Do If You Want To Appeal
a Healthfirst CompleteCare member? . . . . . . 4 A Decision About Your Care. . . . . . . . . . . . . . . 18
Responsibilities of Members. . . . . . . . . . . . . . . 5 Level 1 Appeals (also known as
a Plan Level Appeal). . . . . . . . . . . . . . . . . . . . . 18
Your Right to Use an Advance Directive . . . . . 5
Timeframes for a “standard” appeal . . . . . . . 20
Notice of Information Available on Request . .6
Timeframes for a “fast” appeal. . . . . . . . . . . . 20
We Will Treat You with Fairness and Respect
at all Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Level 2 Appeals. . . . . . . . . . . . . . . . . . . . . . . . . 21
Transitional Care. . . . . . . . . . . . . . . . . . . . . . . . . . 7 External Appeals for Medicaid Only. . . . . . . . 22
Monthly Surplus. . . . . . . . . . . . . . . . . . . . . . . . . . 7 What To Do If You Have A Complaint
About Our Plan. . . . . . . . . . . . . . . . . . . . . . . . . . 23
Money Follows the Person (MFP)/Open Doors. 7
How to File a Complaint. . . . . . . . . . . . . . . . . 23
Services Covered by Healthfirst CompleteCare. . 8
Complaint Appeals. . . . . . . . . . . . . . . . . . . . . . 24
Deductibles and Copayments on Medicare
Covered Services. . . . . . . . . . . . . . . . . . . . . . . . 8 How to make a complaint appeal. . . . . . . . . 24
Who is part of my Healthfirst CompleteCare What happens after we get
Care Team?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 your complaint appeal. . . . . . . . . . . . . . . . . . . 24
What additional services are covered by Disenrollment from Healthfirst CompleteCare 24
Healthfirst CompleteCare?. . . . . . . . . . . . . . . . 8
Termination of Benefits from Voluntary
Can I get care outside of the Service Area?. . 13 Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 24
Emergency Service. . . . . . . . . . . . . . . . . . . . . . . 13 Involuntary Disenrollment. . . . . . . . . . . . . . . . 25
If you have a medical emergency. . . . . . . . . 13 Effective Date of Disenrollment and
Coordination of Transfer to Other
What is covered if you have a medical Service Providers . . . . . . . . . . . . . . . . . . . . . . . 26
emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Re-Enrollment Provisions. . . . . . . . . . . . . . . . 26
What if it wasn’t a medical emergency? . . . . 14
Notice of Non-Discrimination. . . . . . . . . . . . . 27
Payment of medical emergency services . . . 14
Language Assistance Information. . . . . . . . . . 28
What Services are not covered by
Healthfirst CompleteCare?. . . . . . . . . . . . . . . . 14
Services covered by Original Medicare. . . . . 15
2ii CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 3WELCOME to Who is eligible for What is the enrollment process Step 3: Nurse Assessment
Healthfirst CompleteCare enrollment in Healthfirst for Healthfirst CompleteCare ■ ur Clinical Eligibility Nurse will conduct a
O
telephonic or home assessment within 30 days
(HMO D-SNP) Medicaid CompleteCare Medicaid Medicaid Advantage Plus Plan? after you request to enroll in CompleteCare, or
Advantage Plus Plan Advantage Plus Plan? Step 1: Confirm Eligibility for long-term care from CFEEC’s referral.
services
You are eligible to enroll in this plan if you meet the ■ Our Clinical Eligibility Nurse will ask you for
Healthfirst CompleteCare (HMO D-SNP) Medicaid
following criteria: People who would like to join Healthfirst verbal consent to let him/her assess your
Advantage Plus Plan is for people who have Medicare
CompleteCare and who are new to Community healthcare needs and clinical eligibility.
and full Medicaid, and who need long-term care ■ you are age 18 or older.
services. Based Long-Term Care Services must call the ■ Our nurse will ask you to provide verbal
are Medicare Part A and B eligible Conflict-Free Evaluation and Enrollment Center
■ consent that lets your healthcare providers
This handbook tells you about the added benefits (CFEEC) at 1-855-222-8350, Monday to Friday,
give us your medical information, where
you get from CompleteCare. It also tells you how ■ Medicaid Community with Long Term Care eligible 8:30am–8pm; Saturday, 10am–6pm; or visit
applicable. In this instance a blank copy
to ask for a specific service, file a complaint, or nymedicaidchoice.com to find out if they are
live in the plan’s service area (Bronx, Kings will be mailed to your home for a signature to:
disenroll from the plan. The benefits in this handbook ■
eligible to join. A conflict-free evaluation is only
are in addition to the Medicare benefits in the (Brooklyn), Nassau, New York (Manhattan), needed if you are new to long-term care services ➤ identify your healthcare needs (also called
CompleteCare Medicare Evidence of Coverage Orange, Queens, Richmond (Staten Island), and joining for the first time, or if you have not an “initial assessment”).
(EOC). Keep this handbook together with the EOC. Rockland, Sullivan, and Westchester counties). been enrolled in a plan for 45 days. If you are
You need both of them to know what services are transferring from a managed long-term care plan ➤ find out if you are eligible for nursing
■ ave a long-term health problem or disability that
h home level of care.
covered, and how to get them. (MLTC), mainstream Medicaid, or another Medicaid
makes you eligible for nursing home level of care.
Advantage Plus (MAP), you are not required to get
➤ find out if you require community-based
Membership Card ■ re able to stay at home without jeopardy to
a
your health at the time you join the plan.
a CFEEC evaluation.
long-term care services offered by
H3359_GEN22_04 0812-21_C Step 2: Confirm Eligibility for Medicaid and CompleteCare for a continuous period
CompleteCare (HMO D-SNP)
This card does not guarantee coverage. If an emergency exists, go to the
nearest Emergency Room or dial 911.
■ re expected to need one or more of the
a Medicare of more than 120 days.
For Members
Member Services: 1-888-260-1010 (TTY: 1-888-542-3821)
Member: JANE Q. SAMPLE PCP $0 Copay Nurse Help Line: 1-855-687-7333 (TTY: 711)
Teladoc: 1-800-835-2362
following Community Based Long-Term Care ➤ provide and mail you information and a
Health Plan (80840)
Specialist
ER
$0 Copay
$0 Copay
Dental:
Vision:
1-800-508-2047
1-800-753-3311
Services (CBLTCS) for more than Enrolling in CompleteCare is voluntary. If you want
CIN: XXXXXX
Urgent Care $0 Copay Website:
For Providers
healthfirst.org/medicare
to join, you (or someone on your behalf) can call Health Care Proxy form (if you want to
Medical
Eligibility: 1-888-801-1660
Pharmacy
1-866-693-4620
120 days from the date that you join the plan: assign someone you trust to make
RxBIN 004336 RxPCN MEDDADV RxGrp Rx1110
Provider Name: Dr. John Doe Prior Authorization: 1-888-394-4327
Electronic Claims: Payer ID 80141
Help Desk:
Claims: CVS Caremark
P.O. Box 52066
CompleteCare. Our team will help you contact
Provider Phone: 1-212-123-4567
Coverage provided by Healthfirst Health Plan, Inc. CMS: H3359-034
Paper Claims: Healthfirst Claims Dept.
P.O. Box 958438
Lake Mary, FL 32795-8438
Phoenix, AZ 85072-2066
➤ nursing services in the home New York Medicaid Choice to find out more about healthcare decisions for you).
Visit MyHFNY.org to find a doctor, view your benefits, and more! HFNY22
➤ therapies in the home CompleteCare. If you qualify and have a completed
➤ talk about services you may need.
New York Medicaid Choice review, if required,
Your CompleteCare identification card (Member ID ➤ home health aide services
a Healthfirst employee will check your Medicaid Step 4: Sign Enrollment Agreement
card) will be mailed to you. Carry this card with you
➤ personal care services in the home eligibility. We will give you a call to provide you
at all times. You need to show it to your provider. ■ fter the initial assessment, our nurse will ask
A
with more information about the plan and will
➤ private duty nursing you to verbally consent to the Enrollment
schedule a visit for one of our registered nurses
Help from Member ➤ adult day health care to conduct a Community Health Assessment Agreement Transfer Attestation. By providing
verbal consent to complete the Enrollment
Services ➤ Consumer Directed Personal Assistance
Services (CDPAS)
for eligibility to the plan. We will also ask you for
information about your healthcare needs. Agreement Transfer Attestation, you agree to:
There is someone to help you at Member Services ➤ get all covered services from CompleteCare
If you are a hospital inpatient, or live in a place ■ our Medicaid eligibility must be reviewed
Y
7 days a week, 8am–8pm (October through March), and our network providers.
licensed by the State Office of Mental Health (OMH), and approved by the NYC Human Resources
and Monday to Friday, 8am–8pm (April through
September). Call 1-888-260-1010 the Office of Alcoholism and Substance Abuse Administration or Local Department of
➤ participate in CompleteCare according to
(TTY 1-888-542-3821). Services (OASAS) or the State Office for People With Social Services.
the terms and conditions described in
Developmental Disabilities (OPWDD), or are enrolled this handbook.
The State of New York has created a Participant ■ ou must have Medicare Parts A and B in order
Y
in another managed care plan managed by Medicaid,
Ombudsman Program called the Independent to join CompleteCare.
a Home and Community-Based Services waiver Once New York Medicaid Choice and Healthfirst
Consumer Advocacy Network (ICAN) to provide program, or OPWDD Day Treatment Program, or are A licensed representative will schedule a home CompleteCare decide that you are eligible to enroll,
Participants/Members free, confidential assistance on getting services from hospice, you can enroll with visit or telephone call and educate you about the your Medicaid application will be sent to New
any services offered by Healthfirst Health Plan, Inc. our plan upon discharge or termination. product and benefits and help you enroll into York Medicaid Choice (NYMC) and your Medicare
ICAN may be reached toll-free at 1-844-614-8800 application will be sent to Centers for Medicare &
CompleteCare using the Medicaid Advantage Plus
or online at icannys.org. (TTY users call 711, then The coverage explained in this handbook starts on Medicaid Services (CMS) for approval.
application.
follow the prompts to dial 844-614-8800.) your enrollment date in Healthfirst CompleteCare.
2 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 3Your start date will be given to you at the time of You must join a MLTC to get these services. If you ■ ame someone to speak for you about your care
n ■ Support Healthfirst CompleteCare
enrollment. If the start date changes, Healthfirst need to contact NYMC, please call 1-888-401-6582 and treatment.
(TTY 1-888-329-1541). ➤ Tell your Care Team you have concerns about
CompleteCare will let you know. You will get an
■ ake advance directives and plans about
m your care or use the Healthfirst CompleteCare
enrollment confirmation letter that shows your your care. appeals and grievances process.
enrollment date.
What are my rights ■ s eek assistance from the Participant Ombudsman ➤ Review this Member Handbook and follow
After your application is approved, you will get and responsibilities program the steps to get proper care.
a Member ID card within 10 calendar days.
If you do not have your Member ID card and need as a Healthfirst ■ sk for an increase in your services, like your
a ➤ Respect the rights and safety of those involved
to see a provider, call Member Services to check CompleteCare member? personal care services (PCS) and CDPAS. in your care and get help from us to keep your
home safe for your care needs.
your coverage. They can fax your information to *Our plan must obey laws that protect you from
your provider. You can also use your confirmation As a member of Healthfirst CompleteCare, you have discrimination or unfair treatment. We do not ➤ Tell your Care Team the following:
of coverage letter as proof of coverage until you the right to: discriminate based on age, sex (such as gender identity
y if you are leaving the service area
get your Member ID card. ■ receive medically necessary care. or status of being transgender), race, creed, physical
or mental disability (such as gender dysphoria), y if you moved or have a new phone number
During the initial assessment, you will be ■ timely access to care and services. developmental disability, national origin, sexual
evaluated by a registered nurse to determine if orientation, type of illness or condition, or the need for y if you changed providers
you meet the clinical eligibility requirements to
■ edical record privacy when you
m health services. If you want more information or have
get treatment. concerns about discrimination or unfair treatment, y any changes in a health issue that may
join CompleteCare. If your clinical assessment
please call the Department of Health and Human affect your current care
determines that you are not eligible to join ■ r eceive information on care choices in a way
CompleteCare because of health and safety you want it and in a language you know. Services’ Office for Civil Rights at 1-800-368-1019
concerns, we will notify you of the denial of (TTY 1-800-537-7697) or your local Office for Civil Your Right to Use an Advance
■ receive translation services free of charge. Rights. If you have a disability and need help with
enrollment which will then be sent to NYMC or
access to care, please call Healthfirst Member Services Directive
LDSS for final decision. You will be notified once ■ gree to the care you are getting before the
a at 1-888-260-1010 (TTY 1-888-542-3821).
NYMC or LDSS makes the final decision. start of treatment. You have the right to know your options and make
choices about your healthcare.
If CMS or NYMC rejects your enrollment, you will ■ e treated with respect and due consideration
b Responsibilities of Members
get an enrollment denial letter. You can call us at for your dignity. You have the right to get full information from your
1-888-260-1010 (TTY 1-888-542-3821) if you To benefit from enrollment in Healthfirst CompleteCare, providers and other healthcare providers when you
■ r equest and receive a copy of your medical you should try to:
disagree with the decision. If NYMC or LDSS rejects go for medical care. Your providers must explain your
records and ask that the records be changed
your enrollment because you did not meet the medical condition and your choices in a way that you
or fixed. ■ articipate Actively in Your Care and
P
can understand.
eligibility requirements, NYMC or LDSS will tell us. Care Decisions
If we disagree with NYMC’s decision, we will follow
■ t ake part in decisions about your healthcare
or refuse treatment. You also have the right to make choices about your
➤ Speak openly with your provider and Care
the dispute resolution process that is approved by healthcare. To help you, we outlined your rights.
Team about your health and care.
the State Department of Health (SDOH). If we do ■ e free from any form of restraint or seclusion
b
not dispute the rejection or you are found not to used as a means of coercion, discipline, ➤ Ask questions to be sure you know, follow,
■ now about all of your choices. You have the right
K
convenience or retaliation as specified in and review your service plan, and take part to be told about all of the treatment options for
meet the standards for enrollment after the dispute
federal regulations on the use of restraints and in your care management calls. your condition, no matter what they cost or
process is done, NYMC or LDSS will move on with
seclusion. whether they are covered by our plan. This also
your denial of enrollment. If you decide to withdraw ➤ Share in care choices and be in charge of includes being told about programs to help you
your enrollment application before the start date of ■ et care without regard to sex, gender identity,
g your own health. safely manage your medications.
enrollment, Healthfirst CompleteCare will tell NYMC race, health status, color, age, national origin,
or LDSS of the withdrawal by fax. sexual orientation, mental or physical disability, ➤ Complete self-care as planned. ■ now about the risks. You have the right to be
K
marital status, or religion.* told about any risks involved in your care. You
➤ Keep appointments and let the Care Team
must be told if any treatment is part of a research
Withdrawal of Enrollment ■ e told where, when and how to get
b know of changes.
test. You always have the choice of saying no to
the services you need from us, such as experimental care.
Your request for withdrawal must be received ➤ Use network providers for care except in
how you can get covered benefits from
emergencies.
the last day of the month prior to the enrollment out-of-network providers. ■ ou have the right to say no. You can refuse any
Y
month. Healthfirst CompleteCare will mail you a ➤ Tell us if you get health services from care. This includes the right to leave a hospital or
cancellation notice.
■ omplain to New York State Department of
c
non-network healthcare providers. other healthcare place, even if your provider
Health (NYSDOH).
advises you not to leave. You also have the right
Long-term care services are no longer covered by ➤ Take part in policy development by writing to stop taking your medication. But you will take
■ omplain to your local department of social
c
New York’s Fee-For-Service (FFS) Medicaid Program. to us, or calling us. full responsibility for what happens to your body
services and the right to use the New York State
Fair Hearing system and/or a New York State ➤ Take part in the six-month assessment as a result.
External Appeal where appropriate. visit or sooner as needed.
4 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 5■ et a coverage denial reason. If you are denied
G Notice of Information Available We Will Treat You with Fairness If you are You will pay:
coverage, you have the right to get a reason
eligible for:
from us. To get the reason, you will need to ask on Request and Respect at all Times
us for a coverage decision. Medicaid Nothing to Healthfirst
The following information is available upon request. Healthfirst must obey laws that protect you from (no monthly spend CompleteCare
You have the right to give orders about what is to be discrimination or unfair treatment. We do not down/ (NAMI))
done if you are not able to make healthcare choices ■ list of names, business addresses, and official
a discriminate based on age, sex (such as gender
for yourself. positions of the members of Healthfirst’s board Medicaid A monthly surplus to
identity or status of being transgender), race,
of directors, officers, controlling partners, and (with monthly spend Healthfirst CompleteCare
Sometimes people become unfit to make healthcare creed, physical or mental disability (such as gender
owners or partners down/ (NAMI)) as decided by New York
choices for themselves due to accidents or serious dysphoria), developmental disability, national origin,
City Human Resources
illness. You have the right to say what you want to ■ copy of Healthfirst’s most recent annual
a sexual orientation, type of illness or condition, or
Administration/Local
happen if you are in one of these situations. This certified financial statement, balance sheet, and the need for health services.
District of Social Services
means that, if you want to, you can: summary of receipts, and disbursements from
If you want more information or have concerns
a certified public accountant If you are eligible for Medicaid with a surplus and
■ f ill out a written form to give someone the legal about discrimination or unfair treatment, please
power to make healthcare choices for you. your surplus changes while you are a Healthfirst
■ information about member complaints, and call the Department of Health and Human Services’
CompleteCare member, your monthly payment will
ive your providers written orders about how
g aggregated information about grievances Office for Civil Rights at 1-800-368-1019
■ be changed.
you want them to handle your healthcare. and appeals (TTY 1-800-537-7697) or your local Office for
Civil Rights. If you need to call NY Medicaid Choice,
The legal documents that you can use to give
your directions before these situations happen are
■ s teps for protecting confidentiality of medical
records, and other member information
please call 1-888-401-6582 (TTY 1-888-329-1541). Money Follows the
called advance directives. There are many types of
advance directives and different names for them. ■ description of the organizational arrangement
a
If you have a disability and need help with access Person (MFP)/Open
to care, please call Member Services at
Documents called living will and power of attorney and ongoing procedures of Healthfirst’s Quality
Assurance Program
1-888-260-1010 (TTY 1-888-542-3821). Doors
for healthcare are examples of advance directives. If you have a complaint, Member Services can help.
MFP/Open Doors is a program that can help
If you want to use an advance directive, here is what ■ description of the steps followed by Healthfirst
a you move from a nursing home back into your
to do. for experimental or investigational individual
drugs, medical devices, or treatments in
Transitional Care community. You can get MFP if you:
■ et the form. Get a form from your lawyer,
G clinical trials New members can get ongoing treatment from a ■ ave lived in a nursing home for three (3)
h
a social worker, or from an office supply store.
non-network provider for a transitional period of months or longer.
You can also get advance directive forms from ■ s pecific clinical review criteria about a certain
Medicare organizations or from Healthfirst up to 60 days from enrollment. The provider must
condition or disease, or other clinical ■ ave health needs that can be met through
h
Member Services. accept our plan rate payment, agree to our policies,
information, used during utilization review services in your community.
and give us your medical information.
(unless it’s proprietary to Healthfirst) when
■ ill it out and sign it. Remember that this is
F
checking covered services supplied by Healthfirst If your provider leaves the network, you can get MFP/Open Doors has people called Transition
a legal document. Consider having a lawyer
help you prepare it. ongoing treatment for a transitional period of up Specialists and Peers who can meet with you in
➤ individual provider affiliations with the nursing home and talk with you about moving
participating hospitals or other places to 90 days. The provider must accept our plan rate
■ ive copies to the right people. Give copies to
G back to the community. Transition Specialists
payment, agree to our policies, and give us your
your provider and to the person who is making and Peers are different from Care Managers and
➤ licensure, certification, and accreditation medical information.
your decisions. You may also want to give copies Discharge Planners. They can help you by:
to close friends or family members. Be sure to status of participating providers
keep a copy for yourself.
➤ application, procedures, and minimum Monthly Surplus ■ iving you information about services and
g
qualification requirements for Healthfirst supports in the community.
If you know that you are going to be hospitalized, The surplus amount is money determined by the
take a copy with you to the hospital. healthcare providers
New York City Human Resources Administration or ■ f inding services offered in the community to
■ If you are admitted to the hospital, they will ask ➤ information about the education, facility Local District of Social Services and under the rules help you be independent.
you for your signed form. affiliation, and participation in clinical of the medical assistance program that a member
■ v isiting or calling you after you move to make
performance reviews conducted by the must pay monthly to Healthfirst. Members with
■ If you have not signed it, the hospital has forms sure that you have what you need at home.
DOH, of healthcare professionals who a surplus will get an invoice on or about the 15th
and will ask if you want to sign one. are licensed, registered, or certified under of each month. The amount you pay depends on For more information about MFP/Open Doors, or
Remember, it is your choice whether you want to Article 8 of the State Education Law your eligibility for Medicaid and Medicaid’s monthly to set up a visit from a Transition Specialist or Peer,
fill out an advance directive or whether you want surplus program. please call the New York Association on Independent
to sign one if you are in the hospital. By law, no one Living at 1-844-545-7108, or email mfp@health.
can deny you care or discriminate against you ny.gov. You can also visit MFP/Open Doors on the
based on whether or not you have signed an web at health.ny.gov/mfp or ilny.org.
advance directive.
6 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 7Services Covered be available to assist you in other needs that you
may have, including, but not limited to, arranging
or urgently needed care. To get approval for an out-
of-network provider, you or your provider must call
disabled people) and/or home health aide services as
needed by an approved plan of care. Home health care
by Healthfirst appointments and transportation. Your Care Team
will work with you and your provider to decide
Healthfirst Utilization Management at
1-888-394-4327 (TTY 1-888-542-3821).
services not covered by Medicare need a doctor order,
prior approval, and must be medically necessary.
CompleteCare the services you need and make a care plan. This
care plan is called a Person-Centered Service Plan Personal Care Nutrition
(PCSP). The PCSP will be developed with you and
Deductibles and Copayments on anyone you want to help you with your plan of You can get help with one or more activities of Nutrition services include looking at your nutritional
Medicare Covered Services care to meet your healthcare needs. The PCSP will daily life: walking, cooking, cleaning, bathing, using needs, food patterns, and planning nutrition fit for
include your goals, objectives, and special needs as the bathroom, personal hygiene, dressing, feeding, your physical, medical, and environmental needs.
Many of the services that you get are covered nutritional and environment support function tasks. These services also include education and counseling,
well as services you receive. Your CT may contact
by Medicare. They are described in the Healthfirst Personal care services need a physician’s order, prior and the development of a nutritional treatment
your provider to talk about and develop your PCSP.
CompleteCare Evidence of Coverage (EOC). approval, and must be medically necessary. plan. Nutritional services need a doctor order, prior
This care plan will change as your needs change. approval, and must be medically necessary.
Chapter 3 of the EOC explains the rules for using
It will be re-evaluated at least every six (6) months Consumer Directed Personal
in-network providers and getting care in a medical
to ensure your care plan is up to date and we are
emergency or if urgent care is needed. If there are
working towards helping you achieve your health
Assistance Services (CDPAS) Medical Social Services
deductibles or copayments for benefits (see Chapter
goals. During the development of the PCSP, you and This program lets you (also known as the “consumer’), Medical social services include checking the need for,
4 of the EOC, “What is Covered”), we will cover
the care manager will work together to establish or the person acting for you, hire, train, supervise, arranging for, and providing aid for social problems by
the deductibles and copayments because you
goals based on what you both have together arrange back-up coverage, keep payroll records, and a trained social worker. These services will help you
have Medicaid.
identified and prioritize your most important fire the person giving you personal care services. You with concerns about your illness, finances, housing,
If there is a monthly premium for benefits (see problems to work on. can ask to use the CDPAS program at any time. You or environment. They must be medically necessary
Chapter 1 of the EOC), you will not have to pay can disenroll from the program at any time. Healthfirst before approved by Healthfirst.
Your care team will help you with any discharges
that premium, since you have Medicaid. We will will review the level of personal care services, home
from the hospital, or emergency room visits, making
also cover many services that are not covered health aide services, and/or skilled nursing services Home-Delivered Meals and/or
sure you have your medications and follow-up
by Medicare. The sections below explain what you need and write you a plan of care.
is covered.
appointments to keep you safe at home. Your Meals in a Group Setting
care team will also help to educate you on your Once we make your plan of care and tell you how
disease(s), medications, specialty appointments. If You can get meals given to you at home or in
In-network providers will be paid in full directly many hours of services are needed, the next step will
your condition changes significantly, you may also another setting (such as an adult home) if you do
by Healthfirst CompleteCare for each service be for you to find the sufficient number of personal
not have cooking tools or if you have a special need.
authorized and supplied to you, with no copayment be assessed for changes in your care needs. By assistants (PAs) needed to perform the services in
Meals must be medically necessary before approval
or cost to you. If you get a bill for covered services helping you manage all parts of your care, your CT your plan of care. A PA can be a family member,
by Healthfirst.
authorized by us, you are not responsible for paying can find problems early, stop problems from getting friend, neighbor, or former aide—but they must be
the bill. Please call your Care Manager. You may be worse, and help you avoid trips to the hospital and trained to do the work you need. A PA cannot be a
responsible for payment of covered services that emergency room. person legally in charge of your care (like your spouse Social Day Care
were not authorized by us or for covered services or designated representative). The consumer must
Social day care gives members with limited
that you got from providers out-of-network. work with the Healthfirst team to arrange covered
What additional services services with providers or healthcare agencies.
socialization functions, supervision, monitoring, and
nutrition. This program takes place in a safe setting
Who is part of my Healthfirst are covered by Healthfirst during any part of the day, but for less than a
The consumer is in charge of or responsible for
CompleteCare Care Team? CompleteCare? scheduling their PAs. They need to make sure that 24-hour period. Other services may include,
there is coverage if a PA cannot make it to work. but are not limited to, personal care help, teaching
We will arrange and pay for the extra health and daily living skills, transportation, caregiver help,
As a member of Healthfirst CompleteCare, you get The consumer also needs to keep track of their
social services described below. You can get them and case help. Social day care must be medically
Care Management Services. You will be assigned time worked and sign off on time sheets and other
as long as needed to stop or treat your illness or necessary before it is approved by Healthfirst.
a primary care manager (PCM) who will be a important documents.
disability. Your care manager will help point out
Registered Nurse (RN) or a Licensed Social Worker
the services and providers you need. You may
(LSW) who is supported by a Care Team (CT) that
need a referral or an order from your provider for Home Health Care Services Not Non-Emergency Transportation
includes other support staff. This team collaborates
with your primary care provider (PCP) to make up
these services, and you must get them from Covered by Medicare Healthfirst covers transportation costs for you to get
in-network providers. medical care and services. Transportation services are
your personal Interdisciplinary Care Team (ICT). Medicaid-covered home health services include
Your CT will check changes in your health and help supplied by ambulance, ambulette, taxicab, public
If you cannot find an in-network provider, you skilled services not covered by Medicare (e.g.,
coordinate care and services. The CT can help you transit, or other means fit to your medical condition.
must get approval before using an out-of-network physical therapist to supervise maintenance program
with your medical, psychosocial, and environmental An aide can go with you to medical appointments
provider, except when it is for a medical emergency for patients who have reached their maximum
needs. Other members of the support team will if needed.
restorative potential, or nurse to pre-fill syringes for
8 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 9Healthfirst will cover Non-Emergency Medicaid- ■ edical/Surgical Supplies. Items for medical
M Hearing Services Members must get all vision care through Davis
covered transportation provided that it is included use other than drugs, which treat a Vision. All covered vision services must be
as a Managed Long-Term Care benefit by the New specific condition. Members get Medicaid-covered hearing services, medically necessary.
York State Department of Health. such as hearing services and products to ease
■ edical Equipment. Adaptive devices and
M disability caused by the loss of hearing.
Transportation by an approved car service or equipment prescribed by a healthcare provider.
Dental
ambulette services must be arranged by Healthfirst Services include hearing aids, fitting, and dispensing;
We offer members dental care through DentaQuest.
two (2) days before needed. We will send ■ nteral and parenteral nutritional supplements.
E ear molds and replacement parts; hearing aid
Covered services include routine dental services
authorization to the transportation vendor. All non- Liquid nutritional supplements.** checks, evaluations, and repairs; audiology exams
such as preventive dental checkups, cleaning,
emergency transportation should be arranged by and testing; and prescriptions.
■ rosthetics. Artificial substitute or replacement
P X-rays, fillings, and other services. You do not need
calling Member Services at 1-888-260-1010
of a limb. Members must get all Medicaid-covered hearing a referral from your primary care provider to see
(TTY 1-888-542-3821), 7 days a week, 8am–8pm
care from providers through NationsHearing. a dentist.
(October through March), and Monday to Friday, ■ rthotics. Appliances and devices that support
O
All covered hearing services must be medically
8am–8pm (April through September). or fix a movable part of the body. How to Access Dental Services:
necessary but may need prior authorization.
If you do not get pre-approval from Healthfirst ■ rthopedic Footwear. Shoes, shoe additions,
O You must get dental treatment from providers
for non-emergent transportation, you will be or braces used to fix, help, or prevent a Podiatry through DentaQuest. All covered dental services
responsible for the full cost. If you take public deformity or range-of-motion issue in a must be medically necessary. Individual dental
transportation (i.e., MTA transit, Long Island Rail diseased or injured part of the ankle or foot. Members get Medicaid-covered podiatry services procedures may need pre-approval.
Road, and/or Metro-North Rail Road, etc.), you for medically necessary foot care. This includes care
must submit a Member Reimbursement Form to lease note: The plan limits incontinence supplies
P for medical conditions affecting lower limbs; up to If you need to find a dentist or change your dentist,
Healthfirst to get reimbursed. to those manufacturers listed below. We will four routine foot care visits per year. call 1-800-508-2047. They have language services
not cover other incontinence supply brands if needed, too.
This form is on our website at and manufacturers unless your doctor or other Added podiatry benefits include routine foot care
HFMedicareMaterials.org, or you can call Member for other conditions (up to 12 visits per year) and ■ how your Member ID card when you visit
S
provider tells us that the brand is appropriate for
Services to ask for one. Fill out the form and mail it diagnosis and the medical or surgical treatment of your dentist. You will not get a separate dental
your medical needs. However, if you are new to
to the address below. Reimbursement will be mailed injuries and diseases of the feet (such as hammer ID card.
Healthfirst CompleteCare and are using a brand
to you. of incontinence supplies that is not listed below, toe or heel spurs).
we will continue to cover your brand for you for
Social/Environmental Supports
Healthfirst Medicare Plan
Member Services up to 90 days. During this time, you should talk Vision Social and environmental supports are services
P.O. Box 5165 with your doctor to decide what brand is medically and items that support your healthcare needs and
Members get Medicaid-covered vision services as
New York, NY 10274 appropriate for you after this 90-day period. (If you are included in your plan of care. These services
services of optometrists, ophthalmologists, and
disagree with your doctor, you can ask him or her to and items include but are not limited to: home
ophthalmic dispensers such as eyeglasses, medically
Private Duty Nursing refer you for a second opinion.)
necessary contact lenses, and polycarbonate maintenance tasks, homemaker/chore services,
lenses, artificial eyes (stock or custom-made), housing improvement, and respite care. Social
Private duty nursing services are medically necessary Incontinence supplies are limited to Attends,
low-vision aids, and low-vision services. Coverage and environmental supports must be medically
services given to you at your permanent or Comfees, Cuties, Comfortwear, Inspire, Covidien,
also includes the repair or replacement of parts, necessary before approval by Healthfirst.
temporary home by a licensed registered professional SureCare, and K2 Health.
or licensed practical nurses (RNs or LPNs). The examinations for diagnosis and treatment for visual
**Enteral formula limited to nasogastric, defects and/or eye disease. Medicaid-covered Personal Emergency Response
services may be ongoing. Private duty nursing
services need a doctor’s order and prior approval.
jejunostomy, or gastrostomy tube feeding, or examinations for refraction are limited to every Services
treatment of an inborn error of metabolism. two (2) years unless otherwise justified as medically
Enteral formula and nutritional supplements necessary. Medicaid-covered eyeglasses do not Personal Emergency Response Services (PERS)
Non-Medicare Covered Durable are limited to people who cannot get nutrition require changing more frequently than every two is a personal electronic device that lets high-risk
Medical Equipment (DME) and through any other means, and to these (2) years unless medically necessary or unless the patients get help in an emergency. These devices
alert response centers once a “help” button on
Related Supplies conditions: 1) tube-fed people who cannot chew glasses are lost, damaged, or destroyed.
or swallow food and must get nutrition through the device is activated. PERS must be medically
Healthfirst CompleteCare covers any DME covered formula by tube; and 2) people with rare inborn Added vision benefits include one (1) yearly routine necessary before approval by Healthfirst.
by Original Medicare. We will not cover specific metabolic disorders requiring specific medical eye exam, one (1) yearly glaucoma screening (for
brands and manufacturers unless your provider asks formulas to give vital nutrients not available those at high risk), and one (1) pair of eyeglasses Adult Day Health Care
us and provides medical reason. As a dual-eligible through any other means. Coverage of certain (standard lenses and frames) every year or a $400
allowance for non-plan collection frames and Adult day health care includes: medical, nursing,
member, you also get Medicaid-covered DME. New inherited disease of amino acid and organic acid
contact lenses. food and nutrition, social services, rehabilitation
York State Medicaid covers additional prosthetics, metabolism that include low-protein or modified
therapy, leisure time activities (planned meaningful
orthotics, and orthopedic footwear that Medicare protein solid food products.
doesn’t cover. DME supplies are:
10 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 11programs), dental, pharmaceutical, and other
ancillary services. Adult day health care needs
Can I get care outside of Worldwide emergency/urgent care services,
including transportation are subject to a maximum
What Services are not
a physician’s order, prior approval, and must be the Service Area? plan benefit allowance of $200,000 per year. covered by Healthfirst
medically necessary.
When you are outside the service area and cannot If you have an emergency, we will talk with the CompleteCare?
providers who are giving you emergency care to help
Nursing Home Care Not Covered by get care from an in-network provider, we will
There are some Medicaid services that the plan
cover urgently needed care from any provider. manage and follow up on your care. The providers
Medicare (only if you are eligible for who are giving you emergency care will decide when does not cover. You can get these services from
These services are non-emergency, unforeseen
institutional Medicaid) medical illnesses, injuries, or conditions that require your condition is stable and the medical emergency any provider who takes Medicaid by using your
is over. Medicaid Benefit Card. Call Member Services at
To get nursing home care services not covered by immediate medical care.
1-888-260-1010 (TTY 1-888-542-3821) if you
Medicare, the services must follow the treatment After the emergency is over, you can get follow-up have a question about a benefit. Some of the
You are also covered for emergency care and
plan written by the ordering provider, registered care. It is covered by the plan. If your emergency care is services covered by Medicaid using your Medicaid
urgent care worldwide. But Healthfirst will not
physician assistant, certified nurse practitioner, given by out-of-network providers, we will try to arrange benefit card include:
cover any Part D prescription drugs that you get
or certified home health agency. It requires prior for in-network providers to take over your care.
as part of your emergency or urgent care visit
approval and must be medically necessary. ■ Assisted Living Program
in another country.
Inpatient Mental Healthcare over the What if it wasn’t a ■ Certain Mental Health Services, including
190-day Lifetime Medicare Limit Emergency Service medical emergency? ➤ Intensive Psychiatric Rehabilitation
A medical emergency is when you, or someone If it turns out that your medical emergency was not Treatment Programs
Inpatient mental health care over the 190-day
lifetime Medicare limit needs a doctor order, prior with an average knowledge of health and medicine, actually an emergency, as long as you reasonably ➤ Day Treatment
approval, and must be medically necessary. believe that you have medical symptoms that thought your health was in serious danger, we will
require immediate medical attention to prevent loss cover your care. But after the provider said that it was ➤ Case Management for Seriously and
of life, loss of a limb, or loss of function of a limb. not an emergency, we will cover additional care only if: Persistently Mentally Ill (sponsored by
Outpatient Mental Health and The health symptoms may be a sickness, injury, state or local mental health units)
Substance Abuse severe pain, or a medical condition that is quickly ■ y ou go to an in-network provider to get the
additional care, or ➤ Continuing Day Treatment
getting worse or may cause death.
Members can get outpatient mental health and
substance abuse services from any in-network ■ t he additional care you get is considered ➤ Assertive Community Treatment (ACT)
provider. You can self-refer for one assessment If you have a medical emergency: urgently needed care, and you follow the rules
➤ Partial Hospitalization (not covered
for each benefit from an in-network provider in a for getting this urgent care.
■ et help as quickly as possible. Call 911 or
G by Medicare)
12-month period. Pre-approval is only needed for
go to the nearest emergency room, hospital, ➤ Personalized Recovery Oriented
out-of-network service requests, electroconvulsive
or urgent care center. Call for an ambulance
Payment of medical
therapy (ECT), and neuropsychological testing. Services (PROS)
if you need it. You do not need to get approval emergency services
or a referral. ■ Comprehensive Medicaid Case Management
Outpatient Rehabilitation You can get emergency services from any provider.
■ s soon as possible, call Healthfirst about
A But when you get emergency or urgently needed ■ irectly Observed Therapy for
D
Healthfirst CompleteCare (HMO D-SNP) removed your emergency. care from an out-of-network provider, you should Tuberculosis Disease
service limits on physical therapy (PT), occupational ask the provider to bill the plan. ■ ome and Community Based Waiver Program
H
therapy (OT), and speech therapy (ST). Healthfirst ➤ You (or someone else) should call us to
■ If you paid the entire amount yourself when you Services
CompleteCare (HMO D-SNP) will cover medically tell us about your emergency care within
necessary PT, OT, and ST visits that are ordered by 48 hours. Call Member Services at got the care, you need to send us the bill, along ■ edicaid Pharmacy Benefits as allowed by
M
a doctor or other licensed professional. 1-888-260-1010 (TTY 1-888-542-3821), with documentation of any payments you have State Law (select drug categories excluded
7 days a week, 8am–8pm (October made. from Medicare Part D benefit)
To learn more about these services, call Member through March), and Monday to Friday, ■ ou may also get a bill from the provider. Send
Y ■ Methadone Maintenance Treatment Programs
Services at 1-888-260-1010 (TTY 1-888-542-3821), 8am–8pm (April through September).
7 days a week, 8am–8pm (October through us this bill, along with documentation of any ■ ffice for People with Developmental
O
March), and Monday to Friday, 8am–8pm payments you have already made. Disability Services
(April through September). What is covered if you have
■ If the provider is owed anything, we will pay ut-of-network Family Planning services under
O
a medical emergency? them.
■
the direct access provisions
Emergency medical care is covered whenever
➤ If you have already paid the bill, we will ■ ehabilitation Services Provided to Residents of
R
you need it, worldwide. This includes OMH Licensed Community Residences (CRs)
pay you back.
ambulance services.
■ Family Based Treatment Programs
12 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 13Services covered by Original Healthfirst Medicare Plan Concurrent Review Standard Process
Provider Service Intake
Medicare: P.O. Box 5166 You can also ask Healthfirst Provider Service Intake Generally, we use the standard timeframe for giving
New York, NY 10274-5166 to get more of a service than you are getting now. you our decision about your request for a medical
■ ospice services provided to Medicare
H
This is called concurrent review. item or service, unless we have agreed to use the fast
Advantage members
We will authorize services in a certain amount track deadlines.
and for a specific period of time. This is called an Retrospective Review standard review for a prior authorization
A
Services not covered by the plan authorization period.
■
Sometimes we will do a review on the care you are request means we will give you an answer within
or by Medicaid getting to see if you still need the care. We may also three (3) work days of when we have all the
Which services require prior review other treatments and services you already got. information we need, but no later than 14
These services are not covered by the plan or by
Medicaid: authorization? This is called retrospective review. We will tell you if calendar days after we get your request. If your
we do these reviews. case is a concurrent review where you are
■ Conversion or Reparative Therapy Some covered services require prior authorization asking for a change to a service you are already
(approval in advance) from Healthfirst Provider getting, we will make a decision within one (1)
If you have any questions, call Member Services Service Intake before you get them. You or someone What happens after we get your work day of when we have all the information we
at 1-888-260-1010 (TTY 1-888-542-3821). you trust can ask for prior authorization. The following service authorization request need, but will give you an answer no later than
treatments and services must be approved before 14 calendar days after we get your request.
The health plan has a review team to be sure you get
How do I get approval for you get them:
the services we promise. Doctors and nurses are on ■ e can take up to 14 more calendar days
W
Elective (non-emergency) inpatient admissions
treatments or services? if you ask for more time or if we need
■
the review team. Their job is to be sure the treatment
or service you asked for is medically needed and right information (such as medical records from
■ Residential health care facility care
for you. They do this by checking your treatment plan out-of-network providers) that may benefit you.
Service Authorization Request ■ Home health care against acceptable medical standards. If we decide to take extra days to make the
(also known as Coverage decision, we will tell you in writing what
■ Personal care services We may decide to deny a service authorization information is needed and why the delay is in
Decision Request) ■ Personal Emergency Response System (PERS) request or to approve it for an amount that is less than your best interest. We will make a decision as
you asked for. A qualified healthcare professional will quickly as we can when we receive the necessary
You have Medicare and get assistance from Medicaid. ■ Adult and Social Day Care make these decisions. If we decide that the service information, but no later than 14 days from
Information in this section covers your rights for all of you asked for is not medically necessary, a clinical
■ Nutritional Services the day we asked for more information.
your Medicare and most of your Medicaid benefits. peer reviewer will make the decision. A clinical peer
In most cases, you will not use one process for your ■ ocial and environmental services (chore
S reviewer may be a doctor, a nurse, or a healthcare ■ If you believe we should not take extra days, you
Medicare benefits and a different process for your services, home modifications or respite) professional who typically provides the care you asked can file a “fast complaint.” When you file a fast
Medicaid benefits. You will usually use one process for for. You can ask for the specific medical standards, complaint, we will give you an answer to your
both. This is sometimes called an “integrated process” ■ Durable medical equipment (DME)
called clinical review criteria, used to make the complaint within 24 hours. (The process for
because it integrates Medicare and Medicaid processes. ■ Inpatient mental health care decision about medical necessity. making a complaint is different from the process
for service authorizations and appeals. For more
However, for some of your Medicaid benefits, you ■ Bunionectomy and hammer toe repair After we get your request, we will review it under information about the process for making
may also have the right to an additional External either a standard or a fast track process. You or your
■ Partial hospitalization services complaints, including fast complaints, see What
Appeals process. See page 21 for more information provider can ask for a fast track review if you or your To Do If You Have A Complaint About Our Plan.)
on the External Appeals process. ■ Outpatient surgery, if cosmetic provider believes that a delay will cause serious harm
to your health. If we deny your request for a fast track If we do not give you our answer within 14 calendar
Information in this section applies to all of your ■ on-emergency transportation, including
N
review, we will tell you and handle your request under days (or by the end of the extra days if we take them),
Medicare and most of your Medicaid benefits. ambulance services
the standard review process. In all cases, we will review you can file an appeal.
This information does not apply to your Medicare
■ Prosthetic devices and related supplies your request as fast as your medical condition requires
Part D prescription drug benefits. ■ I f our answer is yes to part or all of what you
us to do so, but no later than mentioned below. More
■ utpatient diagnostic tests and therapeutic
O asked for, we will authorize the service or give
When you ask for approval of a treatment or service, services – (i.e., PET scans and radiation therapy) information on the fast track process is below.
you the item that you asked for.
it is called a service authorization request (also
known as a coverage decision request). Comprehensive Dental Services We will tell you and your provider both by phone and in
■ ■ I f our answer is no to part or all of what you
To get a service authorization, you or your provider writing if we approve or deny your request. We will also
■ Private Duty Nursing asked for, we will send you a written notice that
must call Member Services at 1-888-260-1010 tell you the reason for the decision. We will explain what
explains why we said no. Level 1 Appeals (also
(TTY 1-888-542-3821) or write to us at: options you have if you don’t agree with our decision.
■ Consumer Directed Personal Assistance (CDPAS) known as Level 1) later in this chapter tells how
to make an appeal.
14 CompleteCare Member Handbook 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org 15You can also read
