PHP Care Complete FIDA-IDD Plan
How to file a grievance
”Filing a grievance” is another way of saying “making a complaint.” The grievance process is used only for certain types of problems, such as problems related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the grievance process.
Grievances about quality – You are unhappy with the quality of care, such as the care you received in the hospital.
Grievances about privacy – You think that someone did not respect your right to privacy, or shared information about you that is confidential.
Grievances about poor customer service – A health care provider or staff was rude or disrespectful to you.
Grievances about physical accessibility – You cannot physically access the health care services and facilities in a provider’s office.
Grievances about waiting times – You are having trouble getting an appointment, or waiting too long to get it.
Grievances about cleanliness – You think the clinic, hospital or provider’s office is not clean.
Grievances about communications from us – You think the written information we sent you is too difficult to understand.
You may file an internal grievance or an external grievance.
To file an internal grievance, you can:
- Call Participant Services at 1-855-747-5483 or TTY/TDD: 711; OR
- Fax your grievance to us. Our fax number is 1-855-619-4678; OR
- Write your grievance and mail it to us at:
2929 Expressway Drive North
Hauppauge, NY 11749
Most grievances are answered in 30 calendar days. If possible, we will answer you right away. If you call us with a grievance, 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.
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).
You can send your grievance (complaint) to Medicare. The Medicare Complaint Form is available here. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free. Your grievance will be sent to the Medicare and Medicaid team overseeing the PHP Care Complete FIDA-IDD Plan.
Coverage Determinations and Appeals
The process for asking for coverage determinations and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment.
What is a coverage determination?
A coverage determination is an initial decision your Interdisciplinary Team (IDT), PHP Care Complete FIDA-IDD Plan, or an authorized specialist makes about your benefits and coverage or about the amount PHP Care Complete FIDA-IDD Plan will pay for your medical services, items, or drugs. Your IDT, PHP Care Complete FIDA-IDD Plan, or your authorized specialist is making a coverage determination whenever it decides what is covered for you and how much PHP Care Complete FIDA-IDD Plan will pay. Authorized specialists include dentists, optometrists, ophthalmologists, and audiologists.
If you or your provider is not sure if a service, item, or drug is covered by PHP Care Complete FIDA-IDD Plan, either of you can ask for a coverage determination before the provider gives the service, item, or drug.
What is an appeal?
An appeal is a formal way of asking us to review a decision made by your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist and change it if you think a mistake was made. For example, your IDT, PHP Care Complete FIDA-IDD Plan, or authorized specialist might decide that a service, item, or drug that you want is not covered. If you or your provider disagree with that decision, you can appeal.
Note: You are a member of your IDT. You can appeal even if you participated in the discussions that led to the coverage determination that you wish to appeal.
Who can I call for help asking for coverage determinations or making an appeal?
You can ask any of these people for help:
You can call us at Participant Services at 1-855-747-5483 or TTY/TDD: 711.
You can call your Care Manager. Their phone number is on the front of your ID Card.
The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by PHP Care Complete FIDA-IDD Plan. The Participant Ombudsman may be reached toll-free at 1-844-614-8800 (TTY users call 711) or online at icannys.org.
Call the Health Insurance Information, Counseling, and Assistance Program (HIICAP) for free help. The HIICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-701-0501.
Talk to your provider. Your provider can ask for a coverage determination or appeal on your behalf.
Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage determination or make an appeal.
Please go to Chapter 9 of your Participant Handbook or call Participant Services at 1-855-747-5483 or TTY/TDD: 711 for more information on appeals. If you would like to learn the number of grievances, appeals and exceptions that have been filed with PHP Care Complete FIDA-IDD Plan, please call Participant Services at 1-855-747-5483 or TTY/TDD: 711.