How do I?

Prior authorizations and actions

Certain medications and services may need approval from Senior Whole Health of New York before they’re covered. This is called a prior authorization. Prior authorization is usually required in you need a complex treatment or prescription. Since coverage will not be authorized without it, beginning the prior authorization process early is important. Ask your doctor if a prescription drug or treatment is going to require prior authorization so they can start the process.

For more information about the prior authorization process, please review your Senior Whole Health of New York Member Handbook.

What is an action?

An action is when Senior Whole Health of New York denies or limits services requested by you or your provider, or:

  • Denies a request for a referral
  • Decides that a requested service is not a covered benefit
  • Restricts, reduces, suspends or terminates services that we already authorized
  • Denies payment for services
  • Doesn’t provide timely services
  • Doesn’t make complaint or appeal determinations within the required timeframes. Those are considered plan “actions.” An action is subject to appeal. (See “How do I File a Complaint or Appeal” section below for more information.)
What is the timing of a notice of action?

If we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we will send you a notice when we make our decision. If we are restricting, reducing, suspending or terminating an authorized service, our letter will be sent at least 10 days before we intend to change the service.

What's included in the notice of action?

Any notice we send to you about an action will:

  • Explain the action we have taken or intend to take
  • Cite the reasons for the action, including the clinical rationale, if any
  • Describe your right to file an appeal with us (including whether you may also have a right to the state’s external appeal process)
  • Describe how to file an internal appeal and the circumstances under which you can request that we speed up (expedite) our review of your internal appeal
  • Describe the availability of the clinical review criteria relied upon in making the decision, if the action involved issues of medical necessity or whether the treatment or service in question was experimental or investigational
  • Describe the information, that must be provided by you and/or your provider in order for us to render a decision on the appeal.

If we are restricting, reducing, suspending or terminating an authorized service, you have a right to have services continue while we decide on your appeal; how to request that services be continued; and the circumstances under which you might have to pay for services if they are continued while we were reviewing your appeal.

Complaints, grievances and appeals

We understand there may be times when you aren’t completely happy or satisfied. We try our best to deal with your concerns or issues as quickly as possible and to your satisfaction. You may use either our compliant (grievance) process or our appeal process, depending on what kind of problem you have.

If you choose to authorize a representative, complete and return the Appointment of Representative Form.

What is a complaint or grievance?

When you tell us you’re dissatisfied with the care and treatment you receive from our staff or network providers, you’re making a complaint, or grievance. For example, you should file a complaint if:

  • You were treated rudely by our staff or a provider’s staff
  • You were unable to get an appointment or see a doctor in a timely manner
  • The quality of care or services you received was inadequate
How do I file a complaint with Senior Whole Health of New York?

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

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

Senior Whole Health of New York

15 MetroTech Center, 11th Floor

Brooklyn, NY 11201

We will record the information and appropriate staff will review of the compliant. You’ll receive a letter confirming receipt of your compliant and a description of our review process. Be sure to include the date of the incident(s), the parties involved, the reason for your grievance, organization determination or appeal.

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

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

  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 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.

What if I disagree with Senior Whole Health of New York’s decision?

If you are not satisfied with the decision we make concerning your complaint, you may request a second review of your issue by filing an appeal. You must file a complaint appeal in writing. It must be filed within 60 business days of receipt of our initial decision about your compliant. Once we receive your appeal, we will send you a written acknowledgement telling you the name, address and telephone number of the individual we have designated to respond to your appeal. All complaint appeals will be conducted by appropriate professionals, including health care professionals for complaints involving clinical matters. These professionals will not be involved in the initial decision.

We will review your complaints and give you a written answer within one of the two timeframes:

  1. For standard appeals, we will make the appeal decision within 30 business days after we receive all necessary information to make our decision.
  2. If a delay in making our decision would significantly increase the risk to your health, we will use the expedited appeal process. For expedited complaint appeals, we will make our appeal decision within 2 business days of receipt of necessary information.

For both standard and expedited complaint appeals, we will provide you with written notice of our decision. The notice will include the detailed reasons for our decision and, in cases involving clinical matters, the clinical rationale for our decision.

How do I file an appeal?

If you don’t agree with an action we’ve taken, you may appeal within 60 days of the date on our letter notifying you of the action. You may file an appeal of a plan action over the phone or in writing.

  • To file an appeal by phone, call Senior Whole Health of New York Member Services at 1-877-353-0185 (TTY 711)
  • To file an appeal in writing, send a letter to:

Senior Whole Health of New York

Attn: Quality Improvement Department

58 Charles Street

Cambridge, MA 02141

We will record the information and appropriate staff will review of the compliant. You’ll receive a letter confirming receipt of your compliant and a description of our review process. Be sure to include the date of the incident(s), the parties involved, the reason for your grievance, organization determination or appeal.

How do I request to continue service during the appeal process?

If you are appealing a restriction, reduction, suspension or termination of services you are currently authorized to receive, you may ask to continue receiving them while your appeal is being decided. This is called continuation of services. You must make this request no later than 10 days from the date of the notice of action or the intended effective date of the action, whichever is later.

If you continue receiving these services and the appeal is not decided in your favor, you may have to pay for them.

How long will it take Senior Whole Health of New York to decide my appeal?

There are two appeal processes, standard appeal and expedited appeal.

Standard appeal process

We will review your appeal and send you a written decision as quickly as your health condition requires, but no later than 30 days from the day we receive an appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.) During our review you will have a chance to present your case in person and in writing. You will also have the chance to look at any of your records that are part of the appeal review.

We will send you a notice about the decision we made about your appeal that will identify the decision we made and the date we reached that decision.

If we reverse our decision to deny or limit requested services, or restrict, reduce, suspend or terminate services, and services were not furnished while your appeal was pending, we will provide you with the disputed services as quickly as your health condition requires.

Expedited appeal process

If you or your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the action. We will respond to you with our decision within 72 hours. The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.

If we do not agree with your request to expedite your appeal, we will make our best efforts to contact you by phone to let you know that we have denied your request for an expedited appeal and will handle it as a standard appeal. We will also send you a written notice of our decision to deny your request for an expedited appeal within 2 days of receiving your request.

If the Senior Whole Health of New York denies my appeal, what can I do?

If our decision about your appeal is not totally in your favor, the notice you receive will explain your right to request a Medicaid Fair Hearing from New York State. It will also include information on how to obtain a Fair Hearing, who can appear at the Fair Hearing on your behalf, and for some appeals, your right to request to receive services while the Hearing is pending and how to make the request.

Note: You must request a Fair Hearing within 120 calendar days after the date on the Final Adverse Determination Notice.

If we deny your appeal because of issues of medical necessity or because the service in question was experimental or investigational, the notice will also explain how to ask New York State for an “external appeal” of our decision.

What is the New York State Fair Hearings Process?

If we did not decide the appeal totally in your favor, you may request a Medicaid Fair Hearing from New York State within 120 days of the date we sent you the notice about our decision on your appeal.

If your appeal involved the restriction, reduction, suspension or termination of authorized services you are currently receiving, and you have requested a Fair Hearing, you will continue to receive these services while you are waiting for the Fair Hearing decision. Your request for a Fair Hearing must be made within 10 days of the date the appeal decision was sent by us or by the intended effective date of our action to restrict, reduce, suspend or terminate your services, whichever occurs later.

Your benefits will continue until you withdraw the Fair Hearing; or the State Fair Hearing Officer issues a hearing decision that is not in your favor, whichever occurs first.

If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the disputed services promptly, and as soon as your health condition requires but no later than 72 hours from the date the plan receives the Fair Hearing decision. If you received the disputed services while your appeal was pending, we will be responsible for payment for the covered services ordered by the Fair Hearing Officer.

Although you may request to continue services while you are waiting for your Fair Hearing decision, if your Fair Hearing is not decided in your favor, you may be responsible for paying for the services that were the subject of the Fair Hearing.

You can file a State Fair Hearing by contacting the Office of Temporary and Disability Assistance:

NYS Office of Temporary and Disability Assistance Office of Administrative Hearings Managed Care Hearing Unit

P.O. Box 22023

Albany, New York 12201-2023

  • Fax a Printable Request Form: 1-518-473-6735
  • Request by telephone:

Standard Fair Hearing line: 1-800-342-3334

Emergency Fair Hearing line: 1-800-205-0110 TTY/TDD line: 711 (request that the operator call 1 (877) 502-6155)

  • Request in person in New York City:

14 Boerum Place, 1st Floor

Brooklyn, NY 11201

 

For more information on how to request a Fair Hearing, please visit: http://otda.ny.gov/hearings/request/

How do I request a New York State external appeal?

If Senior Whole Health of New York denies your appeal because we determine the service is not medically necessary or is experimental or investigational, you may ask for an external appeal from New York State. The external appeal is decided by reviewers who do not work for us or New York State. These reviewers are qualified people approved by New York State. You do not have to pay for an external appeal.

When we make a decision to deny an appeal for lack of medical necessity or on the basis that the service is experimental or investigational, we will provide you with information about how to file an external appeal, including a form on which to file the external appeal along with our decision to deny an appeal. If you want an external appeal, you must file the form with the New York State Department of Financial Services within four months from the date we denied your appeal.

Your external appeal will be decided within 30 days. More time (up to five business days) may be needed if the external appeal reviewer asks for more information. The reviewer will tell you and us of the final decision within two business days after the decision is made.

You can get a faster decision if your doctor can say that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in three days or less. The reviewer will tell you and us the decision right away by phone or fax. Later, a letter will be sent that tells you the decision.

You may ask for both a Fair Hearing and an external appeal. If you ask for a Fair Hearing and an external appeal, the decision of the Fair Hearing officer will be the “one that counts.”

There will be no change in your services or the way you are treated by Senior Whole Health of New York staff or a healthcare provider because you file a complaint or an appeal. We will maintain your privacy. We will give you any help you may need to file a complaint or appeal. This includes providing you with interpreter services or help if you have vision and/or hearing problems. You may choose someone (like a relative or friend or a provider) to act for you.

If you have any questions, please call Senior Whole Health of New York Member Services at 1-877-353-0185 (TTY 711).

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.

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.