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Service Authorizations

  • A Service Authorization is a request for plan approval of treatments and services.
  • Partners Health Plan must respond to a service authorization within 14 days.
  • If your health is at risk, this will be considered Fast Track and will be decided within 72 hours.
  • If PHP needs more information to make a decision, we may extend our timeframe by 14 days. You will be notified of this in writing.
  • Outcomes of Service Authorizations: Approve, Partially Approve, Deny
  • You will receive an Approval Notice or an Initial Adverse Determination Notice in the mail notifying you of our decision.

Plan Appeals

  • If your Service Authorization was Partially Approved or Denied, you will receive an Initial Adverse Determination Notice. This notice will include your appeal rights and an Appeal Request Form.
  • To file a Plan Appeal, the Appeal Request Form must be returned to Partners Health Plan within 60 days from the date of the Initial Adverse Determination Notice.
  • Partners Health Plan must decide a Plan Appeal within 30 days
  • If your health is at risk, this will be considered a Fast Track Appeal and will be decided within 72 hours.
  • If PHP needs more information to make a decision, we may extend our timeframe by 14 days. You will be notified of this in writing.
  • Partners Health Plan has 30 days to decide the appeal. If PHP needs more information to make a decision, we may extend our timeframe by 14 days.  You will be notified of this in writing.
  • Outcomes of Plan Appeals: Overturn, Partially Overturn, or Uphold the Initial Adverse Determination.
  • If Partners Health Plan Partially Overturns or Upholds their decision, we will mail you a Final Adverse Determination Notice. This notice will include information on Fair Hearings and a Fair Hearing Request Form.
  • Aid to Continue: If Partners Health Plan has decided to reduce, stop, or suspend services and you wish for aid to continue during the appeal process, the Appeal Request Form must be returned to Partners Health Plan within 10 days from the date of the Initial Adverse Determination Notice.

Fair Hearings

  • A Fair Hearing is the chance for you to tell an administrative law judge why you think our decision was wrong. The judge will either uphold or overturn our denials.  The Fair Hearing decision will be final.
  • To request a Fair Hearing, the Fair Hearing Request Form must be returned to the New York State Office of Temporary and Disability Assistance within 120 calendar days from the date of the Final Adverse Determination Notice.
  • Aid to Continue: If Partners Health Plan has decided to reduce, stop, or suspend services and you wish for aid to continue during the Fair Hearing process, the Fair Hearing Request Form must be returned to New York State Office of Temporary and Disability Assistance within 10 days from the date of the Final Adverse Determination Notice.

External Appeals

  • An External Appeal is a review of your case by health professionals that do not work for Partners Health Plan or New York State.
  • You have 4 months from the date of the Final Adverse Determination or from the date you agreed to skip the Plan Appeal process.
  • This will not extend timeframes or request a Fair Hearing
  • There are no Aid to Continue rights when asking for an External Appeal
  • You may ask for both a Fair Hearing and an External Appeals, but the Fair Hearing decision will be the final answer.

If you would like to file a Plan Appeal online, please email appeals@phpcares.org.  For additional questions related to our Service Authorization and Appeals processes, please contact Member Services at 1-855-747-5483.

 

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