PHP Care Complete FIDA-IDD Plan

Here’s everything you need to get the most out of PHP Care Complete FIDA-IDD Plan (2018)

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Annual Notice of Change

Download English PDF     Download Russian PDF     Download Chinese PDF     Download Spanish PDF


 

Participant Rights and Responsibilities

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Nondiscrimination Notice

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Notice of Privacy Practices

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Summary of Benefits

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Evidence of Coverage / Participant and Family Handbook

Download English PDF     Download Russian PDF     Download Chinese PDF     Download Spanish PDF 


Comprehensive Formulary

Download English PDF     Download Russian PDF     Download Chinese PDF     Download Spanish PDF


Multi-language Insert

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Provider Directories by Service Area:

To request a copy of a Provider Directory, please send an email with the name of the requested county and your full mailing address to directoryrequests@phpcares.org.

Can’t find a provider?  Call us at 1-855-747-5483 or TTY/TDD: 711 for the most up to date provider listing.


Medication Therapy Management Program (for eligible participants who opt in)

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Out-of-Network Coverage Rules

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CMS Appointment of Representative Form (CMS Form-1696)

You can ask a friend, relative, your doctor or other provider, or another person to act for you as your “representative“ if you need assistance with a coverage determination, grievance, or appeal.  To give a friend, relative, doctor or other provider, or another person the right to be your representative, download and print a copy of the Appointment of Representative Form in your preferred language.  The form must be signed by you and the person whom you would like to act as your representative.  The completed and signed form must be provided to PHP Care Complete FIDA-IDD Plan and will be valid for 1 year.

Download PDF   SPANISH


Coverage Determination Form (Part D)

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Coverage Redetermination Form (Part D)

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Prior Authorization Criteria (Part D)

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Step Therapy Criteria (Part D)

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Prescription Drug Transition Policy

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Personal Medication List Form

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Abuse (billing)

Billing abuse applies to a range of improper billing behaviors or practices of providers, including, but not limited to:

  • Billing for a non-covered service
  • Billing for a service that was not provided or billing twice for the same service
  • Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered)
  • Upcoding, or billing for a more expensive service than the one that was delivered
  • Inappropriately allocating costs on a cost report.

Abuse (personal)

Personal abuse happens when another person does something on purpose that causes you mental or physical harm or pain. This may include physical abuse, sexual abuse, or emotional abuse.


Access

Your ability to get needed medical care and services on a timely basis.


Action(s)

A denial or a limited authorization by the managed care plan of a requested item or service, or a reduction or termination of a previously authorized service. Actions can be appealed by the participant, the participant’s authorized representative, or a provider acting on the participant’s behalf.


Activities of Daily Living (ADLs)

ADLs are activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.


Administrative Hearing

An administrative hearing is a second level of appeal if the first level of appeal with PHP is not decided wholly in the participant’s favor. For PHP Care Complete participants, the administrative hearing is conducted by the FIDA Administrative Hearing Unit within the New York State Office of Temporary and Disability Assistance.


Admitting physician

The doctor responsible for admitting a patient to a hospital or other inpatient health facility.


Advance directives

Advance directives are written instructions—such as a living will or durable powers of attorney for health care recognized under state law and signed by a patient—that explain the patient’s wishes concerning the provision of health care if the patient becomes incapacitated and is unable to make those wishes known.


Advocate

A person who gives you support or protects your rights.


Ambulatory surgical center

A place other than a hospital that does outpatient surgery. At an ambulatory surgery center, you might stay for only a few hours or for one night.


Appeal

An appeal is a special kind of complaint you make if you disagree with a decision (i.e., plan action) to deny or reduce a request for services or to pay for services you already received. An appeal is your request for a review of an action taken by PHP related to your covered items or services. You can file an appeal with PHP by calling Participant Services or your Care Management Team or by writing a letter.


Assessment

The gathering of information to evaluate your health and other needs. Assessments are performed when you first enroll and at least every 180 days thereafter. You may also receive an assessment if you have a sudden change in your condition or if your caregiver becomes unable to assist you.


Authorization from Interdisciplinary Team (IDT)

Each participant in PHP will have an Interdisciplinary Team to assist in managing his or her needs and services and the development of a written person-centered care and service plan, or “Life Plan.” Most covered services that a PHP participant needs will be authorized by the Interdisciplinary Team and included in the Life Plan. 


Authorized Representative

An organization or adult person authorized under law, to act on behalf of a Participant. Unless otherwise stated, the Representative will have all the rights and responsibilities of a Participant or party in filing a grievance, and in obtaining an organization determination or in dealing with any of the levels of the appeals process.

 

You can get this information for free in other languages. Call 1-855-747-5483, and 711 for TTY users, during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español. Llame a Servicios del Participante al 1-855-747-5483 durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 711. La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a 1-855-747-5483 durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 711. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a pou gratis nan kreyòl ayisyen. Rele sèvis patisipan nan 1-855-747-5483 les heures de 8:00 je pou 8:00 pm, 7 jou nan semenn nan. Utilisateurs TTY ta dwe rele 711. Apèl gratis. Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону 1-855-747-5483 с 8:00 утра до 8:00 вечера, 7 дней в неделю. Пользователи TTY звоните по телефону 711. Звонок бесплатный. 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 1-855-747-5483,辦公時間為上午8時到下午8時,每週7天。聽力語言殘障服務專線(TTY)用戶請撥打711。該電話為免付費通話。 한국어로 된 정보를 무료로 얻을 수 있습니다. 주 7일 오전 8시에서 오후 8시 사이에1-855-747-5483 번(TTY 사용자는 711번)으로 문의해 주십시오. 통화는 무료입니다. You can get this information for free in other formats, such as large print, braille, or audio. Call 1-855-747-5483 and 711 for TTY users during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. This is not a complete list. The benefit information is a brief summary, not a comprehensive description of benefits. For more information contact the plan or read the Participant Handbook. Limitations and restrictions may apply. For more information, call PHP Care Complete FIDA-IDD Plan Participant Services or read the PHP Care Complete FIDA-IDD Plan Participant Handbook. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year.
GET HELP

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Contact us at (855) PHP-LIVE  (747-5483) or TTY/TDD: 711

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