An organization determination is a decision MetroPlusHealth makes about your benefits and coverage or about the amount we will pay for your medical services. We and/or your participating provider make a coverage decision for you whenever you see your provider for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
If you wish to request a coverage decision for medical care, please contact us at:
MetroPlus Health Plan
Utilization Management
50 Water Street, 7th Floor
New York, NY 10004
Phone: 1-866-986-0356, TTY: 711
24 hours a day, 7 days a week
Fax: 1-212-908-4401
When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days of receiving your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours of receiving your request. For a request for a medical item or service, we can take up to 14 more days if you ask for more time or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.
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 your health requires it, ask us to give you a “fast coverage decision.”
A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours. For a request for a medical item or service, we can take up to 14 more days if we find that some information is missing that may benefit you or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days.
To get a fast coverage decision, you must meet two requirements:
- You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
- You can get a fast coverage decision only if 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 agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your provider’s support, our plan will decide whether your health requires that we give you a fast coverage decision.
APPOINTMENT OF REPRESENTATIVE
Did you know?
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for an organization determination (coverage decision). There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, print out and complete the Appointment of Representative form in English or Spanish in the Documents and Forms section below. The form must be signed by you and by the person who you would like to act on your behalf. You must send in or fax a copy of the signed form to 1-212-908-8701.
Grievances
A grievance is a type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. For example, you may complain about how long it takes to make an appointment or about the cleanliness of a provider’s office. This type of complaint does not involve coverage or payment disputes. If you have a complaint, contact us promptly. You have 60 days after the date of the event or incident to make your complaint.
If you need help filing a grievance, the MetroPlus Health Plan Grievance Department is available to help you. You can file a grievance by mail, or by fax. If you have a complaint, please contact Member Services at:
MetroPlus Health Plan
Attn: Medicare Complaints Manager
50 Water Street, 7th Floor
New York, NY 10004
Phone: 1-866-986-0356
Fax: 1-212-908-3011
We will try to resolve your complaint over the phone or within 24 hours of receipt of complaint. If you would like a written response to your verbal complaint, we will send you a written response.
If we are unable to resolve your complaint over the phone, we have a formal complaint process called the Member Complaints & Grievances Procedure. The Member Services Representative will advise you that they are forwarding your verbal complaint to our Complaints Unit for investigation and resolution. If you wish to put your complaint in writing and mail it to us please mail it to the address above or fax it.
We will answer your complaint either in writing or by telephone (or both) no more than 30 days after the day we receive your letter. If you ask us to, or if we need more than 30 days to respond to your complaint, we may take another 14 days to answer.
If you are making a complaint because we denied your request for a fast coverage decision, 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.
You can also submit grievances/complaint directly to Medicare at medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-204.
Appeals
An appeal is a request to review the organization determination we made. For example, you can file an appeal if we did not pay for emergency or urgently needed care or if we discontinued a service or type of care you think you need.
Appeals can be standard or fast. A response to a standard appeal can take up to 30 days after we receive your request if your appeal is about coverage for services you have not yet received. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within 7 calendar days after we receive your appeal. If you believe your health or your ability to function could be hurt by waiting for a standard appeal, you may request a fast appeal. We will make a decision on a fast appeal within 72 hours.
If you wish to appeal a coverage decision for medical care, please contact us at:
Standard Appeal
MetroPlus Health Plan
50 Water Street, 7th Floor
New York, NY 10004
Phone: 1-866-986-0356, TTY: 711
24 hours a day, 7 days a week.
Fax: 1-212-908-8824
Fast (Expedited) Appeal
MetroPlus Health Plan
Attention: Appeals Coordinator
50 Water Street, 7th Floor
New York, NY 10004
Phone: 1-866-986-0356, TTY: 711
24 hours a day, 7 days a week.
Fax: 1-212-908-8824
Appeals may be sent via mail or fax. Verbal appeals are also accepted and followed up in writing by the Plan.
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to complete an Appointment of Representative form located in the Documents and Forms section below. The form must be signed by you and the person who you would like to act on your behalf. You must mail or fax a copy of the signed form to 1-212-908-8824. You may submit your Appointment of Representative form by mail or fax.
Appointment of Representative form
Mail: MetroPlus Health Plan
Attention: Appeals Coordinator
50 Water Street, 7th Floor, 33 Maiden Lane
New York, NY 10004
Fax: 212-908-4401
When we receive an appeal, we review the coverage decision we made to check if we were following all of the rules properly. When we have completed the review, we give our decision.
If we say no to all or part of your Level 1 Appeal, we will automatically send your case for a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
View the most recent CMS National Coverage Determination (NCD) Notices here.
For more information, see your plan’s Evidence of Coverage.
Formulary Exceptions, Coverage Determination, and Drug Appeals
If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception”. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When CVS Caremark receives a request for payment, or to provide a Part D drug to a member, CVS Caremark must determine whether or not the request is necessary and appropriate, and what your part of the cost is for the drug. These actions by CVS Caremark are known as “coverage determinations”.
Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary).
Request a Coverage Determination including Formulary Exceptions and Drug Appeals
You can contact us at any time and ask us if a drug is covered by calling us at 1-866-693-4615 (TTY: 711), 24 hours a day, 7 days a week. If you request an exception, your doctor must provide a statement to support your request. Once we receive a statement from your doctor, we must make a coverage determination and notify the affected member within 72 hours of receiving the request, or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours.
We accept request for a coverage determination by mail, email, phone, or fax.
CVS Caremark Part D Services
Coverage Determinations & Appeals
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000
Phone: 1-866-693-4615 (TTY: 711)
24 hours a day, 7 days a week
Fax: 1-855-633-7673
[email protected]
Please note: Often, CVS Caremark will not have all of the information it needs to make a coverage determination. In those cases, an extra 2 weeks is allowed to gather all necessary supporting documentation. In addition, if we approve your exception request for a non-formulary drug, you cannot request an exception to the copay you must pay for the drug.
You can find the Medicare Prescription Drug Coverage Determination Form and the Medicare Prescription Drug Coverage Redetermination Form below in the Documents and Forms section or use the online forms linked below.
Medicare Prescription Drug Coverage Determination Online Form
Medicare Prescription Drug Coverage Redetermination Online Form
The Part D Coverage Determination form is also available by visiting the Centers for Medicare and Medicaid Services (CMS) website.
Out of Network Coverage Rules
Generally, you must obtain your treatment from MetroPlusHealth network providers. However, some exceptions apply such as:
- if you require emergency services,
- urgently needed care or
- kidney dialysis services you are out of the service area.
In these circumstances, prior authorization to seek out-of-network care is not required. However, to make sure the service(s) will be covered we ask that if you are able please call Member Services at 1-866-986-0356. (TTY users should call 711). Our hours are 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for non-English speakers.
In the event you require specialized services that are not available within the MetroPlusHealth network, please contact Member Services to obtain prior authorization for out-of-network services. If MetroPlusHealth approves the out of network services your cost sharing for these services will be the same as if you had received your care from a network provider.
You may check your Evidence of Coverage for additional information.
Pharmacy
We encourage you to use MetroPlusHealth’s in-network pharmacies at all times to fill your prescriptions. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave.
We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- Example 1: You are traveling outside of the service area and you run out of or lose your covered Part D drug(s) or become ill and need a covered Part D drug, and you cannot access a network pharmacy.
- Example 2: You cannot obtain a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-per-week service.
- Example 3: You must fill a prescription for a covered Part D drug in a timely manner and that drug is not regularly stocked at accessible network retail or mail-order pharmacies.
- Example 4: You are provided covered Part D drugs dispensed by an out-of-network institution- based pharmacy while you are a patient in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting, and as a result cannot get your medications filled at a network pharmacy.
- Example 5: During any Federal disaster declaration or other public health emergency declaration in which our members are evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy
Obtaining an Aggregate Number of Grievances, Appeals, and Exceptions filed with MetroPlus Advantage Plan & Platinum Plan
To obtain the aggregate number of grievances, appeals, and exceptions filed with MetroPlus Health Plan, please call our Member Services Department at 1-866-986-0356 (TTY: 711) 24 hours a day, 7 days a week.
