Grievance, Coverage Determination and Appeals

You have the right to file a grievance and to ask us to reconsider decisions we have made

The MetroPlus FIDA Plan Participant Handbook (page 199) tells what you can do if you have any problems or concerns about your covered services or care. For example, you could ask us to make a coverage decision, make an appeal to us to change a coverage decision, or file a grievance.
 
You have the right to get information about appeals and grievances that other Participants have filed against MetroPlus FIDA Plan.
 
You may file an internal grievance or an external grievance. An internal grievance is filed with and reviewed by MetroPlus FIDA Plan. An external grievance is filed with and reviewed by an organization that is not affiliated with MetroPlus FIDA Plan. 
 
To file an internal grievance, call Participant Services at 1.844.288.FIDA (3432), TTY users: 711, Monday through Saturday, 8 am - 8 pm. After 8 pm, Sundays & Holidays: 24/7 Medical Answering Service at number listed above. The grievance must be made within 60 calendar days after you had the problem you want to complain about.
 
  • If there is anything else you need to do, Participant Services will tell you.
  • You can also write your grievance and send it to us. If you put your grievance in writing, we will respond to your grievance in writing.
  • If you need a response faster because of your health, we will give you an answer within 48 hours after we get all necessary information (but no more than 7 calendar days from the receipt of your grievance).
  • If you are filing a grievance because we denied your request for a “fast coverage decision” or a “fast appeal,” we will respond to your grievance within 24 hours.
  • If you are filing a grievance because we took extra time to make a coverage decision, we will respond to your grievance within 24 hours.
To file an external grievance (complaint) complete and submit a Medicare Complaint Form on the Medicare website. 
If you asking for a standard appeal, make your appeal in writing or call us.

You can submit a request to the following address:

MetroPlus Health Plan
160 Water Street, 3rd Floor
New York, NY 10038
Attn: UM Department

Or fax to: 1.212.908.4401 
 
MetroPlus FIDA Participants can contact us at 1.844.288.FIDA (3432), Monday through Saturday, 8 am - 8 pm. After 8 pm, Sundays & Holidays: 24/7 Medical Answering Service at 1.800.442.2560. TTY users: 711.

What to do if you believe you are being treated unfairly or your rights are not being respected

If you believe you have been treated unfairly - and it is not about discrimination for the reasons listed on page 212 - you can get help in these ways:
  • You can call Participant Services and file a grievance with MetroPlus FIDA Plan as outlined in Chapter 9, section 10, page 199.
  • You can call the Health Insurance Information, Counseling and Assistance Program (HIICAP) at 1.800.701.0501.
  • You can call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users: 1.877.486.2048.

Appointment of Representative Form  

You have the right to 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 a coverage decision or make an appeal. 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 (English / espaƱol). 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 (1.212.908.8701) MetroPlus a copy of the signed form.