• Coverage Decisions, Appeals and Grievances

  • Requesting an Organization Determination

    You can ask us to make a coverage decision to cover the medical care you want. This is also called requesting an organization determination: You, your doctor, or your representative can call or fax us at the numbers below:

    • Call 888.543.9074, Monday – Friday, 8:30 am to 5:00 pm ET
    • Fax 718.794.7822
    • Or mail to:
      Affinity Health Plan
      Medical Management
      1776 Eastchester Road
      Bronx, NY 10461

    Generally, we will give you an answer within 14 calendar days after we receive your request.

    However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

    If we do not give you our answer within 14 calendar days (or if there is an extended time period, by the end of that period), you have the right to appeal. 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 14 calendar days after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

    If our answer is no to part or all of what you requested, we will send you a written statement explaining the decision.

    If your health requires, you can request a “fast coverage decision,” which means we will answer within 72 hours.

    • However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.
    • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. We will call you as soon as we make the decision.

    If you ask for a fast coverage 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 decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.
    • If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal. Section 5.3 below tells how to make an appeal.

    If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

    If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.

    To get a fast coverage decision, you must meet two requirements:

    • You are asking for coverage for medical care you have not yet received.
    • Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

  • Appeals and Grievances

    Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

  • Making an Appeal

    If we make a coverage 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 a coverage decision we have made.

    When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

  • How to Make a Level 1 Appeal

    Step 1

    You contact us and make your appeal. If your health requires a quick response, you must ask for a "fast appeal".

    What to do

    • To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing.
    • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Send the appeal request to:

      Affinity Health Plan
      A&G Unit- Quality Management Department
      Metro Center Atrium
      1776 Eastchester Road
      Bronx, NY 10461

      Or, fax it to 718.536.3385, attention Appeals and Grievances Unit

      You may also ask for an appeal by calling us for free at:
      888.543.9069
      Monday through Sunday, 8:00 am to 8:00 pm
      TTY: 711
      • If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form (English | Spanish) authorizing this person to represent you. It is also available on Medicare’s website. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.
       
    • If you are asking for a fast appeal, make your appeal in writing or call us at 888.543.9069. Calls to this number are free. We are open Monday through Sunday, 8:00 am to 8:00 pm. TTY users can call 711.
    • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
    • You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
      • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you.
      • If you wish, you and your doctor may give us additional information to support your appeal.
       

    If your health requires it, ask for a “fast appeal”
    A “fast appeal” is also called an "expedited reconsideration."

    • If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”
    • To start a fast appeal you, your doctor, or your representative, must contact us either by phone or in writing. Send the fast appeal request to:

      Affinity Health Plan
      A&G Unit- Quality Management Department
      Metro Center Atrium
      1776 Eastchester Road
      Bronx, NY 10461

      You may also ask for a fast appeal by calling us for free at:
      888.543.9069
      Monday through Sunday, 8:00 am to 8:00 pm
      TTY: 711
    • If your doctor tells us that your health requires a “fast appeal”, we will give you a fast appeal
    Step 2

    What We Do
    We consider your appeal and we give you our answer.

    • When we are reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.
    • We will gather more information if we need it. We may contact you or your doctor to get more information.

    Deadlines

    For a “fast” appeal

    • 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.
      • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing.
      • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.
    • 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 72 hours 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 a Level 2 Appeal.

    For a “standard” appeal

    • 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.
      • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days.
      • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
      • If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
    • 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 a Level 2 Appeal.
    Step 3

    If our plan says no to part or all of your appeal

    • Your case will automatically be sent on to the next level of the appeals process
    • To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the “Independent Review Organization.” When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2
  • Filing a Grievance

  • How to File a Grievance

    Step 1

    Contact us promptly – either by phone or in writing.

    • Calling Customer Services is the first step. If there is anything else you need to do, Customer Services will let you know. You can call us at 877.234.4499. Calls to this number are free. We are open 8:00 am to 8:00 pm, Monday through Sunday. TTY users can call 711.
    • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
    For Medical Grievances

    You can send your written complaint to Affinity Health Plan Customer Service/Medicare, Affinity Health Plan, Metro Center Atrium, 1776 Eastchester Road, Bronx, NY 10461.

    After we receive your written grievance, you will receive an acknowledgement letter from us within 5 days. The letter will summarize your grievance, tell you who is working to resolve your grievance, how to contact this person, and whether we need more information from you. You will receive a letter from us within 24 hours if your grievance involves a decision to not conduct an expedited organization/coverage determination or reconsideration or to take extensions on initial decision or appeals. If you disagree with this decision, you can file an expedited grievance with our plan. We must notify you by mail of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

    • Whether you call or write, you should contact Customer Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
    • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
      • What this section calls a “fast complaint” is also called an “expedited grievance.”
    Step 2

    We look into your complaint and give you our answer.

    • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
    • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
    • If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
  • You can also submit a complaint directly to Medicare. To submit a complaint to Medicare, go to medicare.gov/MedicareComplaintForm. If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 800.MEDICARE (800.633.4227). TTY users can call 711.


  • Pharmacy

    A grievance is a complaint about any problem you had with Affinity or one of our network pharmacies. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations.

  • What to Do

    Contact Us Immediately

    If you (your appointed representative) have a grievance, please:

    • Call Customer Service:
      866.362.4002
      TTY: 711
    • Fax: 866.633.7673
    • Mail:
      CVS Caremark Inc
      Part D Services
      MC109
      P.O. Box 52000
      Phoenix, AZ 85072-2000
    Expedited Grievances

    If you are grieving the decision by Affinity not to expedite an initial determination or an appeal, you can request an expedited grievance. In these situations, Affinity will respond to you within 24 hours.

    Appeals

    Once Affinity notifies you of a decision regarding a coverage determination request, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Similar to coverage determinations, there is a fast track and routine process for handling appeals.

    You have a right to appeal if you think Affinity:

    • Decided not to cover a drug, vaccine, or other Part D benefit
    • Decided not to reimburse you for a Part D drug that you paid for
    • Reimbursed you less than you feel you should have received
    • Asked you to pay a different cost-sharing amount than you think you are
    • Required to pay for a prescription
    • Denied your exception request

    We will consider your appeal thoroughly and promptly. The time frames listed above will give you an idea of when you can expect a response from Affinity. It is important to let us know as soon as possible that you wish to file an appeal. If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination.

    You may fax your Appeal request to 866.633.7673 or mail it to the following address:

    CVS Caremark Inc
    Part D Services
    MC109
    P.O. Box 52000
    Phoenix, AZ 85072-2000

    To request a fast appeal, you may call 866.362.4002, 24 hours a day, seven days a week. TTY users can call 711.

    If your complaint is regarding a quality of care issue (for example, you believe our pharmacist provided you with the incorrect dose of a prescription) you may also file a complaint with the Quality Improvement Organization (QIO), called Island Peer Review Organization (IPRO) by calling 800.331.7767 or for TTY, 866.446.3507. A QIO is a group of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Quality Improvement Organization review process is designed to help stop any improper medical practices.

    Who May Ask for a Grievance or an Appeal?

    You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form (English | Spanish) and send it to us with your request. You can call us at 877.234.4499 or for TTY at 711 if you need help filling out the form or want to learn more about appointing a representative.

  • H5991_AffinityMedicarePlanWebsite2018A Pending Last updated 6/28/2018


  • Affinity Health Plan is an HMO and HMO-SNP Plan with a Medicare contract and a contract with the New York State Medicaid Managed Care Program. Enrollment in Affinity Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance and restrictions may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Premiums, Part D co-pays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Affinity Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 877.234.4499 (TTY: 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 877.234.4499 (TTY: 711) 。