How do I?

Service authorizations, actions, appeals and complaints

You have Medicare and get assistance from Medicaid. Information in this section covers your rights for all your Medicare and most of your Medicaid benefits. The information below applies to all your Medicare and Medicaid benefits. This is called an integrated process because it integrates the Medicare and Medicaid process.

However, for some of your Medicaid benefits, you may also have the right to an additional External Appeals process. See go to the New York State External Appeals section for more information on the External Appeals process.

What is a Service Authorization Request (also known as Coverage Decision Request, or an Action)?

When you ask for approval of a treatment or service, it’s called a service authorization request.

How do I request a service authorization request?

To get a service authorization request, you or your provider may call Member Services or send your request in writing to:

Senior Whole Health of New York NHC

15 MetroTech Center, 11th Floor

Brooklyn, New York

11201

If we approve your request, we will authorize services in a certain amount and for a specific period of time, called an authorization period.

What happens after I get my service authorization request?

A review team made up of doctors and nurses looks at all requests to determine whether the treatment or service is medically needed and right for you. There are two review timeframes:

1.Standard Process– Generally, we use the standard process for giving you our decision.

  • A standard review for a prior authorization process will give you an answer within 3 workdays. If we need to gather more information, it may take up to 14 calendar days.
  • If you are asking for a change to a service you are already getting, we will give you a decision within 1 workday. If we need to gather more information, it may take up to 14 calendar days. We will notify you if we need more time.

If you don’t believe we should take extra days to gather information, you can file a fast compliant. When you file a fast complaint, you’ll receive an answer within 24 hours. For more information on filing a fast complaint, please go to the “How do I file a grievance” section.

If one of the following outcomes happens during the standard process, you may file a Level 1 Appeal:

  • If we do not give you an answer with 14 calendar days (or by the end of the extra days if we take them), you may file an appeal.
  • If our answer is no to part or all of what you asked for, you may file an appeal.

2.Fast Track Process– If your health requires it, you or your doctor may ask for a fast track process or fast service authorization. This means we will give you an answer within one of these two timeframes:

  • Within one workday of the day we have all of the information we need, but no later than 72 hours from when you made your request to us.
  • Up to 14 extra calendar days if we find information that may benefit you (such as a medical record from out-of-network providers) or if you need extra time to get us information.

If you believe we should not take extra days, you can file a fast complaint. For more information about the process for making a complaint, please go to the “How do I file a grievance” section.

To get a fast service authorization, you must meet two requirements:

  1. You are asking for coverage for medical care you have not gotten yet. (You cannot get a fast service authorization if your request is about payment for medical care you already got.)
  2. Using the standard deadlines could cause serious harm to your life or health or hurt your ability to function.

If one of the following outcomes happens during the Fast Track Process, you may file a Level 1 Appeal:

  • If we do not give you an answer with 72 hours (or by the end of the extra days if we take them), you may file an appeal.
  • If our answer is no to part or all of what you asked for, you may file an appeal.

 For more information about Service Authorization Requests, please review your Member Handbook. At any time in the process, you or someone you trust can also file a complaint about the review timeline with the New York State Department of Health by calling 1-866-712-7197.

What if I disagree with the decision you made?

You have the right to file an appeal whenever you disagree with a decision we make about your care. An appeal is a request that we reconsider our decision about your Service Authorization Request.

How do I file a Level 1 Appeal?

You can file an appeal yourself or ask someone you trust to file the Level 1 Appeal for you. You can file a Level 1 Appeal:

By phone:

1-877-353-0185 (TTY 711)

By mail:

Senior Whole Health of New York NHC

15 MetroTech Center, 11th Floor

Brooklyn, New York

11201

To appoint a representative to act on your behalf, please do one of the following:

Can I continue getting the service while I wait for the appeal decision?

If we told you we were going to stop, suspend, or reduce services or items that you were already getting, you may be able to keep those services or items during your Level 1 Appeal. This is called an Aid To Continue authorization. To do this, you will need to ask for a Level 1 Appeal within 10 calendar days of the date on your Integrated Coverage Determination Notice or by the intended effective date of the action, whichever is later.

For more information about the Level 1 Appeal process, including your right to further appeal, please refer to your Member Handbook or Evidence of Coverage (EOC). You may also contact Member Services at 1-877-353-0185 (TTY 711).

How do I file a complaint?

You may file a complaint over the phone or in writing.

  • To file a complaint by phone, call 1-877-353-0185
  • To file a complaint in writing, send a letter to:

Senior Whole Health of New York NHC

15 MetroTech Center, 11th Floor

Brooklyn, NY 11201

Be sure to include the date of the incident(s), the parties involved, the reason for your grievance, organization determination or appeal.

We will record the information and appropriate staff will review your compliant. You’ll receive a letter confirming receipt of your compliant and a description of our review process.

We’ll review your compliant and give you a written answer within one of the two timeframes below.

  1. For standard complaints, you’ll get an answer within 45 days from the date we received all necessary information.
  2. If a delay in an answer would significantly increase the risk to your health, we’ll use the expedited complaint process. For expedited complaints, we will make a decision within 2 business days after receipt of necessary information, but no more then 7 (seven) calendar days from receipt of the compliant.

The review period can be increased up to 14 days if you request it or if we need more information and the delay is in your interest.

Our answer will describe what we found when we reviewed your compliant and our decision.

You may also contact the New York State Department of Health anytime for filing complaints by calling them at 1-866-712-7197 or writing to them at:

Bureau of Managed Long Term Care
New York State Department of Health
Corning Tower Room 1911
Empire State Plaza
Albany, NY 12237

Fraud, waste and abuse

Health care fraud, waste and abuse is a serious problem and it affects everyone.

What is fraud?

Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get a benefit or money. Fraud is intentional with knowledge that the information is false.

What is waste?

Waste is when someone overuses health services carelessly. Waste isn’t always intentional

What is abuse?

Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

Examples of fraud, waste and abuse:

   Providers:

  • Providing medical services that are not needed
  • “Up-coding” – charging for a more complex or expensive service than was given
  • Billing for services that were not provided
  • Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
  • Billing for rented medical equipment after it has been returned
  • Billing twice for the same service
  • Billing for more services than can be performed in one day
  • Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Members:

  • Using another person’s name to get Medicaid services
  • Sharing a member ID card or using another person’s member ID card
  • Visiting several doctors to get multiple prescriptions
  • Lying to a care coordinator or someone else to try and get a service you don’t need
  • Paying a doctor cash for a prescription that is not needed
  • Making false documents by changing:
  • The date of service
  • Prescriptions
  • Medical records
  • Referral forms
How do I report suspected fraud, waste & abuse?

Reporting suspected fraud, waste and abuse is easy— and it’s important.

Senior Whole Health of New York’s Fraud Hotline
1-800-341-4915

Magellan Health’s Anonymous Compliance Hotline
1-800-915-2108

Other ways to report suspected fraud:

Office of Inspector General (OIG)
To report suspected cases of fraud, waste, or abuse in Federal Health and Human Services (HHS) programs, you may fill out the online OIG Hotline form. You can also call, mail or fax using the information below:

Office of Inspector General
U.S. Department of Health & Human Services
ATTN: HOTLINE
PO Box 23489
Washington, DC 20026

Phone: 1-800-HHS-TIPS (8477)
TTY: 1-800-377-4950
Fax: 1-800-223-8164

Centers for Medicare and Medicaid Services 
1-800-MEDICARE (1-800-633-4227)

Senior Whole Health of New York’s Civil Rights Coordinator

Civil Rights Coordinator, Corporate Compliance Department
8621 Robert Fulton Drive
Columbia MD 21046

Phone: 1-800-424-7721
Email: compliance@magellanhealth.com

Magellan Fraud, Waste and Abuse Policy

How to choose a primary care provider (PCP)

It’s important to find the right PCP for you. Look for someone who can meet your individual needs—someone who speaks your language or has a wheelchair accessible exam room.

We make it easy to find high quality health care providers in New York City. Use our Find a Provider searchable online provider directory here. You can search for providers by the following ways:

  • Provider name
  • Provider specialty
  • Distance
  • Whether they are accepting new patients
  • What languages they speak
  • What hospitals they’re affiliated with
How can I change my primary care provider (PCP)?

Senior Whole Health of New York members can change their PCP at any time. Just call Member Services and we can help.

When does a PCP change begin?

PCP/provider changes will begin the first of the month following your change request. For example, if you change your PCP/provider on April 1, the change will go into effect beginning May 1.

You’ll get a new Senior Whole Health of New York member ID card with the name and phone number of your new PCP.

How can I still get care if my PCP/provider retires?

If your PCP/provider retires or leaves the plan, Senior Whole Health of New York will send a letter to let you know. This letter is generally sent at least 30 days before your PCP leaves the plan. However, sometimes circumstances prevent us from alerting you 30 days in advance, such as if your PCP/provider passes away unexpectedly. If you need help finding a new PCP, call member services. We’ll help you find someone who speaks your language, specializes in treating your condition and meets your unique needs.

How do I make the most of my doctor visit?

Make the most of the time you have with your doctor. Watch this short video to learn more.

What are Medicare Part B drugs?

Medicare Part B covers a limited number of outpatient prescription drugs under limited conditions. Usually, Part B drugs are medical drugs you wouldn’t give to yourself. They are administered at a doctor’s office or hospital outpatient setting.

Do Part B drugs require prior authorization?

Some of these drugs require prior authorization. You can view the drugs requiring prior authorization here:

Part B Prior Authorization Drug List  (English)

Part B Prior Authorization Drug List (Spanish)

If your treatment includes any of the medical drugs listed, ask your provider if this change affects you. If so, your provider must submit a Prior Authorization request by fax to Senior Whole Health of New York NHC at 1-508-823-6375.

  • Your provider must give us supporting documentation with all requests.
  • Your provider must provide your treatment history information.

How do I request a new ID card?

Once you’re enrolled in Senior Whole Health of New York, you’ll get a member ID card. This card has important information for you and your providers.

Always show your member ID card when you go to a health care provider or pharmacy.

If your member ID card is ever damaged, lost or stolen, call Member Services right away at  1-877-353-0185. We will mail you a new card.

How do I follow and use a care plan?

Once you are enrolled in Senior Whole Health of New York, you will work with your care manager on creating your person-centered care plan. Your care plan will include the types of health services that you need and how you will get them. It will also include your goals and preferences.

Together, we work as a team which includes your care manager, your doctor(s) and most importantly you (and a caregiver or family member, if desired). Your care team will work with you to update your care plan when your healthcare needs change, and at least once per year.

How do I enroll & disenroll in Senior Whole Health of New York?

Visit our Senior Whole Health of New York enrollment and disenrollment page here.

How do I renew?

Once you’re enrolled in Medicare, you don’t need to take action to renew your coverage every year. Your Medicare coverage will automatically renew every year unless you fail to pay any necessary premiums.

You need to recertify your Medicaid coverage annually. The Human Resources Administration (HRA) or Local departments of Social Services (LDSS) will send you recertification instructions. You will also receive a reminder in the mail from us. If you need help completing your recertification, please call Member Services at 1-877-353-0185.

What is a Health Care Proxy

The New York Health Care Proxy Law allows you to appoint someone to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes

Learn more about the New York Health Care Proxy Law.*

Download NY Health Care Proxy Form