Commercial - Appendix: New York |
INTRODUCTION
The information provided in this appendix pertains to physicians
and other health care providers who provide care to members covered under a
ConnectiCare of New York, Inc. benefit plan. The Practitioner Due Process Rights
Section of this appendix only applies to physicians and other health care
practitioners who participate with ConnectiCare as part of our New York-based
provider network.
PHYSICIAN & PROVIDER-RELATED INFORMATION
I. Physician Responsibilities
• Provide ConnectiCare written notification of changes
in status (e.g., termination of participation, closing practice to new patients)
60 days in advance so that ConnectiCare may send written notice to impacted
members within required time frames.
• OB/Gyns should provide HIV pretest counseling with clinical
recommendation of testing for all pregnant members. They should also inform them
that they and their newborns have access to services for positive management of
HIV disease, psychosocial support and case management for medical, social, and
addictive services.
• All participating providers must develop policies and procedures to assure the
confidentiality of HIV-related information. Such policies and procedures should
include the following: initial and annual in-service education of staff and
contractors, identification of staff allowed to access the information and
limits of access; procedures in place to limit access to trained staff
(including contractors); protocol for secure storage (including electronic
storage); procedures for handling requests for HIV-related information; and
protocols to protect persons with or suspected of having HIV infection from
discrimination.
• Participating providers must make medical records
available to ConnectiCare for the purposes of utilization review and quality
assurance. Such records must also be made available to the New York State
Department of Health, at no expense to the Department for management and/or
financial audits, program monitoring and evaluation, licensure or certification
of facilities or individuals and as otherwise required by State Law.
Additionally, providers are required to retain medical records for six (6) years
after the date of service or cessation of the plans operation (for minors,
records must be retained for six (6) years after the date of majority).
II. Practitioner Due Process Rights
Pursuant to applicable law and the provisions of its practitioner
contracts, ConnectiCare has the right to terminate, suspend, or restrict
practitioners participation with ConnectiCare if their conduct adversely affects
or could adversely affect the health or welfare of a member or members, such as
by failing to remain in compliance with ConnectiCares credentialing criteria,
losing privileges with an institutional provider, or having sanctions or
restrictions imposed upon licensure.
Practitioners have the right to appeal ConnectiCares decision to
take adverse action against them in accordance with applicable New York law and
Health Care Quality Improvement Act of 1986.
Either party may exercise the right of non-renewal as permitted
under the applicable provider agreement. Any non-renewal shall not constitute a
termination for purposes of appeals.
Practitioners terminated for the following reasons will not have
the right to appeal:
• determination of fraud,
• imminent harm to patient care as determined by ConnectiCare, or
• final disciplinary action by a licensing board or government agency, which impairs the practitioners ability to
practice.
Procedure:
1. Should ConnectiCare make the decision to
reduce, suspend or terminate a practitioner's participation "for cause",
ConnectiCare shall provide written notice to the practitioner stating:
• that disciplinary action has been proposed against the practitioner;
• the reasons for the proposed action;
• that the practitioner has the right to request a hearing on the proposed action;
• that the practitioner has thirty-five (35) calendar days from the date of the notice
within which to request such a hearing; and
• a summary of the practitioners rights in the hearing.
2. If a hearing is requested on a timely
basis by a practitioner who is sent such notice, ConnectiCare shall send to the
practitioner a notice providing:
• the place, time, and date of the hearing, which shall be within thirty (30) calendar days from
the date of ConnectiCares receipt of the practitioners request for a hearing; and
• a list of witnesses (if any) expected to testify at the hearing on behalf of ConnectiCare.
3. The appeals hearing shall be held before a subcommittee of ConnectiCares Quality
Improvement Committee (QIC). The subcommittee shall consist of three practitioners who
are not in direct economic competition with the practitioner involved. At least one person on
such panel shall be a clinical peer in the same discipline and the same or similar
specialty as the practitioner under review.
4. The right to an appeals hearing may be forfeited if the practitioner fails, without
good cause, to appear.
5. At the appeals hearing, the practitioner has the right:
• to representation by an attorney or other person of the practitioners choice;
• to have a record made of the proceedings, copies of which may be obtained by the
practitioner upon payment of any reasonable charges associated with the preparation
thereof;
• to present evidence determined to be relevant by the subcommittee, regardless of its
admissibility in a court of law; and
• to submit a written statement at the close of the hearing.
6. Within fourteen (14) calendar days of the completion of the appeals hearing, the
subcommittee shall render its decision to either reinstate, provisionally reinstate
with conditions set forth by the plan, or to terminate. The QICs decision shall be final.
The decision, along with the basis of its decision shall be communicated, in writing,
to the practitioner within five (5) business days of its having reached such decision. In
no event shall termination be effective earlier than thirty (30) days after receipt by
the practitioner of the subcommittee s decision, but no earlier than sixty (60)
days from receipt of the notice of termination.
7. In accordance with the requirements of applicable federal and state law, ConnectiCare
shall notify the appropriate regulatory authority of any final decision of the QIC to
reduce, suspend, or terminate a practitioners participation for quality-related reasons.
8. ConnectiCare will not terminate or refuse to renew a contract with a provider solely for the following actions:
• Advocating on behalf of a member,
• Filing a complaint against ConnectiCare,
• Appealing a decision of ConnectiCare,
• Providing information to members and prospective members regarding a condition
or course of treatment, including the availability of other therapies, consultations, or
tests, or the provisions, terms or requirements of the Plans products as they
relate to the member, and
• Requesting a hearing or review.
III. Utilization Review
If ConnectiCare fails to make a medical necessity determination
within the required time period, the determination will be considered an adverse
determination that is subject to appeal.
IV. Overpayments
ConnectiCare will coordinate the recovery of overpayments to
providers in accordance with recent New York legislation. The process is
consistent across all lines of business and follows these guidelines:
• Other than for recovery of duplicate payments, ConnectiCare will provide 30 days written
notice to physicians or providers before engaging in additional efforts to seek
recovery of overpayments.
• Notice will include patient name, date of service, payment amount, proposed adjustment, and
a specific explanation of the adjustment.
• ConnectiCare will not look back more than 24 months for payment, except for cases of suspected
fraud and abuse, recoveries required or initiated by a self-insured plan, or
required by a state or federal government program.
Member-Related Information
I. Continuity of Care
In accordance with New York law, ConnectiCare will provide
continuity of care coverage, according to the members Plan, under the following conditions:
1. A member, covered under a plan that has referral requirements, has a condition that is more
appropriately managed by a specialist.
• If ConnectiCare or the PCP determines that the members care would most appropriately be
coordinated by a specialist or specialty care center with expertise in treating
the members condition or diagnosis, then ConnectiCare will collaborate with the
PCP to make a referral to such specialty or specialty care center.
• Care rendered by the specialist or specialty care center under such circumstances will be exempt
from any PCP-to-specialist referral requirements once the initial authorization
has been granted. If the service that the member needs is not available from a
participating specialist or specialty care center, then services will be
authorized at the in-network level of benefits for a non-participating
specialist or specialty care center.
2. An in-network provider chooses to terminate participation in the ConnectiCare network.
• Members may continue to receive care from their provider for a period of up to ninety (90)
days from the date of the provider's contract termination.
• Members who are pregnant and in their second trimester of pregnancy may continue care with their
physician through the post-partum period.
3. The member is receiving treatment from a non-participating provider upon the effective date
with their Plan.
• The member has a life-threatening or degenerative and disabling condition are entitled to a
transitional period of up to sixty (60) days from their effective date of enrollment.
• If a member is in her second trimester of pregnancy, she may continue care with her physician
through the post-partum period.
Note: Providers who render services to members as outlined under the Continuity
of Care section must accept ConnectiCare's reimbursement rates, adhere to
utilization management requirements, and comply with requests from ConnectiCare
for medical information related to the care of a member during the above-noted
periods in order for ConnectiCare to approve any of the transitional care
discussed under this section.
II. Emergency Care
An emergency medical condition is defined as a medical or
behavioral condition, the onset of which is sudden, that manifests itself by
symptoms of sufficient severity, including severe pain that a prudent layperson
possessing an average knowledge of medicine and health could reasonably expect
the absence of immediate medical attention to result in:
• placing the health of the person afflicted with such condition in serious jeopardy, or in
the case of a behavioral condition, placing the health of such person or others
in jeopardy; or,
• serious impairment to such persons bodily functions; or,
• serious dysfunction of any bodily organ or part of such person; or,
• serious disfigurement of such person.
III. Member Complaints, Grievances, and Appeals
Members or their designee can always ask questions or submit
complaints, grievances or appeals related to benefits and other issues
concerning their plan. Since most questions or complaints can be resolved
informally, we suggest that members contact our Member Services Department
first. In addition, members may also contact the New York State Insurance
Department or the New York State Department of Health or at any time during the
complaint process for help and assistance:
Consumer Services Bureau State of New York Insurance Department
Agency Building One
Albany, NY 12257
1-800-342-3736
or
Bureau of Managed Care Certificate & Surveillance
New York State Department of Health
Corning Tower, Room 1911, Empire State Plaza
Albany, NY 12237
Complaint Hotline: 1-800-206-8125
Complaints may be initiated orally, electronically or by mail by
calling, faxing or writing us as follows:
Telephone: 1-800-846-8578
Facsimile: (860) 674-2866 or 1-800-319-0089
ConnectiCare of New York, Inc.
Member Appeals
P.O. Box 4061
Farmington, CT 06034-4061
Complaints
A complaint is defined as any issue of dissatisfaction with
ConnectiCare's operations expressed by a member or a member's designee that is
not a result of a determination made by ConnectiCare. ConnectiCare will respond
to complaints not resolved within the same telephone call, or face-to-face
encounter, in writing within fifteen (15) days to advise the member of the
resolution of the complaint, or that the resolution is in process, with a
resolution and explanation to follow in a timely manner. Complaints will be
resolved within thirty (30) days of receipt.
Grievances
A grievance is defined as any dissatisfaction regarding a
determination made by ConnectiCare (other than dissatisfactions concerning
determinations of medical necessity). Grievances may include, but are not
limited to, denials of access to a referral or a determination that a benefit is
not covered.
1. Upon receipt of the grievance, ConnectiCare will provide notice to the member of any additional information
needed in order to render a decision on the grievance.
2. ConnectiCare will provide written acknowledgment of the grievance within fifteen (15) days, including the name,
address, and phone number of the department designated to respond to the grievance.
3. If the member’s grievance involves a clinical matter, it will be reviewed by a licensed, certified or registered
health care professional.
4. The member or his/her designee will be provided with a written decision within the following time frames:
• fifteen (15) calendar days from receipt of the grievance for pre-service grievances
• thirty (30) calendar days from receipt of the grievance for post-service grievances
5. In cases where a delay may significantly increase the risk to the member’s health, we will:
• immediately inform the member of any information necessary in order to render a decision on
the grievance; and
• advise the member that this information must be provided to ConnectiCare within twenty-four (24)
hours; and
• advise the member that we will make a grievance determination based on the available information,
if the necessary information is not received by the time due; and
• provide the member or his/her designee with a written decision within thirty-six (36) hours
from receipt of the grievance; and
• immediately notify the member or his/her designee by telephone of the determination.
6. Notification of all grievance
determinations will include the reason for the determination, the clinical
rationale (if applicable), and the procedure for requesting an appeal if the
member is not satisfied with the determination.
IV. Appeal Process
If the member or their designee is not satisfied with a decision
we (or our Delegated Programs) have made regarding Health Services, benefits,
pre-authorization, pre-certification, claims, complaints, or grievances, then
he/she may request an appeal. The appeal process is divided into two
categories:
1. Administrative (Non-Medical Necessity)
Appeals: A request for review of a complaint or grievance decision.
2. Medical Necessity Appeals: A request for
review of an adverse determination, such as a denial of a request for
pre-certification of an inpatient admission or the pre-authorization of a
certain surgical procedure. This also includes requests for health care services
denied as experimental or investigational.
In either case, the appeal request may be initiated orally, electronically or by mail by calling, faxing or writing us as follows:
Telephone: 1-800-846-8578
Facsimile: (860) 674-2866 or 1-800-319-0089
ConnectiCare of New York, Inc.
Member Appeals
P.O. Box 4061
Farmington, CT 06034-4061
When contacting us, the member or the member's designee should
explain why he/she feels the original decision should be overturned and submit
any other relevant information. The appeal must be made as soon as possible
after the member’s receipt of the original decision, but no later than six (6)
months after the complaint/grievance decision, six (6) months after the
pre-authorization of payment was denied, or six (6) months after the claim for
benefits was denied, whichever comes first.
Administrative (Non-Medical Necessity) Appeal
If the member or his/her designee is not satisfied with a
complaint or grievance decision, such as a decision that interprets the
application of Plan rules and that does not relate to an adverse determination,
he/she may appeal that decision.
1. Upon receipt of the appeal, ConnectiCare
will provide notice to the member of any additional information needed in order
to render a decision on the appeal.
2. When this appeal is submitted, it will be
acknowledged in writing within fifteen (15) business days of receipt. The
acknowledgment will include the name, address and telephone number of the
department designated to respond to the appeal.
3. Appeal decisions of non-clinical matters
will be made by a qualified person who is at a higher level than the person who
made the complaint or grievance determination. If the appeal involves a clinical
matter, then the decision will be made by a clinical peer reviewer who was not
involved in the initial determination.
4. The member or his/her designee will be provided with a written decision within the following time frames:
• fifteen (15) calendar days from receipt of the appeal for pre-service appeals
• thirty (30) calendar days from receipt of the appeal for post-service appeals
5. In cases where a delay may significantly increase the risk to the member’s health, we will:
• immediately inform the member of any information necessary in order to render a decision on
the appeal, and
• advise the member that this information must be provided to ConnectiCare within 24 hours;
and
• advise the member that we will make an appeal determination based on the available information, if
the necessary information is not received by the time due; and
• notify the member or his/her designee of the decision within seventy-two (72) hours
from receipt of the original complaint or grievance.
6. Notification of the appeal determination
will include the reason for the determination, and the clinical rationale (if
applicable).
Medical Necessity Appeal
The member and ConnectiCare may jointly agree to waive the
internal appeal process. If this occurs, ConnectiCare will provide a letter to
the member agreeing to such a waiver within twenty-four (24) hours of the
agreement. This letter will include information about how to file an external
appeal.
If we do not render our decision about an appeal within the time
limits as required by law, the appeal will be considered resolved in the
member’s favor.
Standard Medical Necessity Appeal
Our medical necessity appeal process is designed to resolve
appeals quickly and impartially through the use of clinical peer reviewers.
1. When this appeal is submitted, it will be
acknowledged in writing within fifteen (15) days of receipt and forwarded for
review. If we require additional information, we will notify the member in
writing within fifteen (15) days of receipt the appeal specific information we
need. If only receive a portion required information, will again notify five (5)
business this partial missing information.
2. We will arrange to have this appeal reviewed by a board-certified physician specialist in the field related to the
condition that is the subject of the appeal who was not involved in our original
decision.
3. Standard appeal determinations will be made within thirty (30) calendar days from receipt of the appeal for pre-service
appeals and within sixty (60) calendar days of receipt of the appeal for
post-service appeals.
4. The member or his/her designee and, where appropriate, the member’s health care provider, will be notified in writing of
the appeal determination within two (2) business days of the decision, but no
later than thirty (30) calendar days from receipt of the appeal for pre-service
appeals and sixty (60) calendar days of receipt of the appeal for post-service
appeals.
5. Notification of the appeal determination will include the reason for the determination, the clinical rationale (if
adverse determination is upheld on appeal), and applicable external appeal
rights.
6. If the member or his/her designee is not
satisfied with the appeal determination, then he/she may request a utilization
review external appeal through the New York State Department of Insurance.
Please refer to the "Utilization Review External Appeal" provision found
later in this section.
Expedited Medical Necessity Appeal
If the member or his/her designee disagree with a decision
regarding a health service that is immediate and urgently needed, the member may
request an expedited appeal of that decision. To file an expedited appeal, call
1-888-977-3434 anytime, twenty-four (24) hours a day, seven (7) days a week. An
expedited appeal can occur for continued or extended health care services,
procedures or treatments, additional services for a member undergoing a course
of continued treatments or when the health care provider believes an immediate
appeal is warranted, except any retrospective determination.
1. When this appeal is submitted, we will immediately notify the member and the provider by telephone or fax of specific
information that we require in order to process the request. We will follow the
phone call or fax with written notification.
2. This appeal will be reviewed by a board-certified physician specialist in the field related to the condition that
is the subject of the appeal who was not involved in our original decision.
ConnectiCare will make the clinical peer reviewer conducting the appeal
available to the provider within one business day of the request.
3. In the case of the concurrent review of the member’s continued hospitalization, the member or his/her designee will be
sent a decision the earlier of: a. prior to the member being discharged from the
inpatient facility; b. within two (2) business days after our receipt of all
necessary information; or, c. within seventy-two (72) hours after our receipt of
the member's request.
4. The member or his/her designee will be sent a decision within two business days after our receipt of all necessary
information, but no later than seventy-two (72) hours after our receipt of the
member’s request.
5. The member of his/her designee will be sent written notice of the final adverse determination within 24 hours of the
rendering of such determination.
6. If the member or his/her designee is not satisfied with the decision, he/she is entitled to further appeal through
ConnectiCare’s standard appeal process or the member or his/her designee may
request a utilization review external appeal through the New York State
Department of Insurance. Please refer to the "Utilization Review
External Appeal" provision found later in this section.
Utilization Review External Appeal
Health care providers may request an external appeal on their own
behalf to obtain payment from ConnectiCare when there has been a retrospective
adverse determination. The member, his/her designee, or his/her health care
provider, has the right to an external appeal when:
A.
1. The member has received an adverse determination of a covered benefit on the grounds that the service is not
medically necessary; and
2. We have issued a final adverse determination or both the member and ConnectiCare have agreed to
waive the member’s internal appeal rights, or
B.
1. We have issued a final adverse
determination on a request for coverage on the grounds that the service is
experimental or investigational, or both the member and ConnectiCare have agreed
to waive the member’s internal appeal rights; and
2. The member’s attending physician has
certified that the member has a life-threatening or disabling condition or
disease: a. for which standard health services or procedures have been
ineffective or would be medically inappropriate; or b. for which there does not
exist a more beneficial standard health service or procedure covered by the
health care plan; or c. for which there exists a clinical trial; and
3. The member’s attending physician must
have recommended either: a. a health service or procedure (including a
pharmaceutical product) that, based on two documents from the available medical
and scientific evidence, is likely to be more beneficial to the member than any
covered standard health service or procedure; or, b. a clinical trial for which
the member is eligible. Any physician certification provided under this section
shall include a statement of the evidence relied upon by the physician in
certifying his or her recommendation; and
4. The specific service or procedure
recommended by the attending physician would otherwise be covered except that we
determined that the service or procedure is experimental or
investigational.
The member or his/her designee will lose the right to an external
appeal if he/she does not file an application for external appeal within
forty-five (45) days of receipt of the final adverse determination from
ConnectiCare.
The external appeal application will instruct the member to send
it to the NY State Insurance Department. The member or his/her designee must
release all pertinent medical information concerning the member's medical
condition and request for services. An independent external appeal agent
approved by the state will review the member's request to determine if the
denied service is medically necessary and should be covered by the plan. All
external appeals are conducted by clinical peer reviewers. The agent’s decision
is final and binding on both the member and the Plan.
An external appeal agent must decide an external standard appeal
within thirty (30) days of receiving the application for external appeal from
the State. Five (5) additional business days may be added if the agent needs
additional information. If the agent determines that the information submitted
to it is materially different from that considered by the plan, the plan will
have three additional business days to reconsider or affirm its decisions. The
member or his/her designee and the plan will be notified in writing within two
business days of the external review agent’s decision.
The member or his/her designee may request an external expedited
appeal if the member's doctor can attest that a delay in providing the
recommended treatment would pose an imminent or serious threat to the member's
health. The external appeal agent will make a decision within three days for
external expedited appeals. Every reasonable effort will be made to notify the
member or his/her designee and the plan of the decision by telephone or fax
immediately. This is followed immediately by a written notice.
The member, his/her designee, or his/her health care provider may
obtain the external appeal application from any of the following:
• ConnectiCare Member Services Department (1-800-846-8578);
• New York State Department of Health website (www.health.state.ny.us);
• New York State Department of Insurance website (www.ins.state.ny.us/extrappqa.htm), or by
telephone (1-800-400-8882)
The utilization review external appeal must be submitted to the
New York State Insurance Department in writing within forty-five (45) days of
receipt of our final denial notice. The forty-five (45) day time frame for
requesting external appeal begins upon receipt of the final adverse
determination of the 1st level appeal. A copy of the application for the
utilization review external appeal will be sent by us in our final written
decision letter. The application may either be faxed or mailed by certified or
registered mail. If faxed, the member or his/her designee must call
1-888-990-3991 to advise the Insurance Department that a request has been
faxed.
New York State Insurance
Department
P.O. Box 7209
Albany, NY 12224-0209
Telephone:
1-800-400-8882
Fax: 1-800-332-2729
This appeal will require a fee of $50 payable to ConnectiCare of
New York, Inc. It will be refunded if the appeal is decided in the member’s
favor. This fee may be waived in cases of extreme financial hardship.
The member or his/her designee will be sent a written decision by
the review panel. The final decision will be binding on us.
V. Pre-authorization Requirements
View a complete listing of Services & Procedures Requiring Pre-Authorization for ConnectiCare of New York products.
Note: The listing of services and procedures that require pre-authorization is subject
to change. ConnectiCare will notify you, in advance, of such changes.
