Rights, Appeals, and Disputes

We must provide information in a way that works for you (in languages other than English, in Braille, in large print, or other alternate formats, etc.)

To get information from us in a way that works for you, please call Member Services department at 1-800-247-1447 (TTY 711). From October 1st through February 14th, we are open seven (7) days a week from 8:00 a.m. to 8:00 p.m. and from February 15th through September 30th, we are open Monday through Friday from 8:00 a.m. to 8:00 p.m.

Our plan has non-English speaking representatives and free language interpreter services available to answer questions from non-English speaking members. We can also give you information in Spanish, in an audio format, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of a disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you.

If you have any trouble getting information from our plan because of problems related to language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048.

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area.

If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights.

If you have a disability and need help with access to care, please call our Member Services department. If you have a complaint, such as a problem with wheelchair access, Member Services can help.

As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services (Chapter 3 of your Evidence of Coverage explains more about this). Call Member Services to learn which doctors are accepting new patients. We do not require you to get referrals.

As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.

If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9, Section 10 of your Evidence of Coverage tells what you can do. (If we have denied coverage for your medical care or drugs and you don’t agree with our decision, Chapter 9, Section 4 of your Evidence of Coverage tells what you can do.)

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. 

• Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.
• The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?

• We make sure that unauthorized people don’t see or change your records. 
• In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you. 
• There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. 
  • For example, we are required to release health information to government agencies that are checking on quality of care. 
  • Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.

You can see the information in your records and know how it has been shared with others 

You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine. 

If you have questions or concerns about the privacy of your personal health information, please call our Member Services department.

As a member of Fidelis Care, you have the right to get several kinds of information from us. 

If you want any of the following kinds of information, please call Member Services: 

Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare health plans. 

Information about our network providers including our network pharmacies. 

• For example, you have the right to get information from us about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network. 
• For a list of the providers and pharmacies in the plan’s network, see the Provider and Pharmacy Directory.
• For more detailed information about our providers or pharmacies, you can call our Member Services department or visit our website at www.fideliscare.org.

Information about your coverage and the rules you must follow when using your coverage. 

• In Chapters 3 and 4 of your Evidence of Coverage, we explain what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services. 
• To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of your Evidence of Coverage plus the plan’s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.
• If you have questions about the rules or restrictions, please call Member Services.
  

Information about why something is not covered and what you can do about it. 

• If a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service or drug from an out-of-network provider or pharmacy.  
• If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 of your Evidence of Coverage. It gives you the details about how to make an appeal if you want us to change our decision. 
• If you want to ask our plan to pay our share of a bill you have received for medical care or a Part D prescription drug, see Chapter 7 of your Evidence of Coverage.

You have the right to know your treatment options and participate in decisions about your health care.

You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand. 

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

• To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
• To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments. 
• The right to say “no.”  You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
• To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of your Evidence of Coverage tells how to ask the plan for a coverage decision.

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:

• Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself. 
• Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

• Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. 
• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.
• Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. 

• If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. 
• If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive(including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the New York State Department of Health.

If you have any problems or concerns about your covered services or care, Chapter 9 of your Evidence of Coverage tells what you can do. It gives the details about how to deal with all types of problems and complaints. 

What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Member Services.

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

If it is about discrimination, call the Office for Civil Rights

If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.

Is it about something else?

If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:

• You can call Member Services.
• You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3 of your Evidence of Coverage. 
• Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.  

How to get more information about your rights

There are several places where you can get more information about your rights: 

• You can call Member Services at 1-800-247-1447 (TTY 711).
• You can call the SHIP. For details about this organization and how to contact it, go to Chapter 2, Section 3 of your Evidence of Coverage. 
• You can contact Medicare.
• You can visit the Medicare website to read or download the publication “Your Medicare Rights & Protections.” By clicking this link, you will leave the Fidelis Care website.
• Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. 

Visit Medicare Resources and click on your plan to learn what is covered for you and the rules you need to follow to get your covered services.

If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Member Services to let us know. 

• We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We’ll help you coordinate your benefits.

Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care or Part D prescription drugs.

Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. 

• To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. 
• Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
• If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.

Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.

As a plan member, you are responsible for these payments:

• You must pay your plan premiums to continue being a member of our plan.
• In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B. For that reason, some plan members must pay a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan.
• For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). Please refer to your Evidence of Coverage for what you must pay for your medical services and your Part D prescription drugs.
• If you get any medical services or drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost. 
  • If you disagree with our decision to deny coverage for a service or drug, you can make an appeal. Please see Chapter 9 of your Evidence of Coverage for information about how to make an appeal.
• If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage.
• If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly to the government to remain a member of the plan.

If you are going to move, it’s important to tell us right away. Call Member Services.

• If you move outside of our plan service area, you cannot remain a member of our plan. We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area.
• If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.
• If you move, it is also important to tell Social Security (or the Railroad Retirement Board).

Any determination made by a Medicare health plan with respect to any of the following:

• Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
• Payment for any other health services furnished by a provider other than the Medicare health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan;
• The Medicare health plan’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the Medicare health plan;
• Reduction, or premature discontinuation of a previously authorized ongoing course of treatment;
• Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee;

Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility.

In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care. 

Grievances do not involve problems related to approving or paying for Part D drugs, Part C medical care or services (see Appeal).

Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service.

As a member you or your authorized representative may file an organization determination, grievance and/or appeal within 60 days of the date of the event or incident by calling our Member Services Department at 1-800-247-1447 (TTY users should call 711). You may also submit your request faxing it to 1-877-533-2402 or in writing to:

Fidelis Care New York
Member Services Department 
95-25 Queens Boulevard 
Rego Park, NY 11374 

Be sure to include the following:

Your Name, Address and Telephone Number 

Your 9 digit Fidelis Care Member Identification Number 

The date of the incident(s), the parties involved, the reason for your grievance, organization determination or appeal. 

All non-urgent requests will be acknowledged in writing. For grievances you should receive a response within 30 calendar days. 

For all organization determination requests or payment appeals you will receive a written response within 60 calendar days. Any organization determination or appeal that is not found in your favor will automatically forwarded to the IRE for another level of review. 

If you have any questions on the process or the status of your requests please call our Member Services Department at 1-800-247-1447, TTY users should call 711. From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week. From February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m. 

In order to receive a report on the number of grievances or appeals that are filed with the plan you can place your request in writing by fax or to the address above. 

This time period may be extended by up to 14 days if the member asks for such an extension or if Fidelis Care can prove the need to extend the time frame. 

Late Filing After 60 days of the Incident-Good Cause Conditions Upon Which a Plan May Grant a Good Cause for Late Filing Exception: If you submit good cause for your late filing in writing Fidelis Care may extend the time frame for filing a request for reconsideration. 

An enrollee, or any physician (regardless of whether the physician is affiliated with the Fidelis care), may request an expedited organization determination when you or your physician believes that waiting for a decision under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy.

Expedited organization determinations may not be requested for cases in which the only issue involves a claim for payment for services that the enrollee has already received. However, if a case includes both a payment denial and a pre-service denial, the enrollee has a right to request an expedited appeal for the pre-service denial. 

When asking for an expedited organization determination, the enrollee or a physician must submit either an oral or written request directly to Fidelis Care by calling our Member Services Department, Faxing to Member Services Department or if applicable, to the entity responsible for making the determination. A physician may also provide oral or written support for an enrollee’s own request for an expedited determination. 

If Fidelis Care decides to expedite the request, we must render a decision as expeditiously as the enrollee’s health condition might require, but no later than 72 hours after receiving the enrollee’s request; and if the plan denies the expedited request it must automatically transfer the request to the standard time frame and make a determination within 14 calendar days from the date the request.

You, Your Physician or Authorized Representative should call or fax Member Services.

If Fidelis Care approves your request for an expedited reconsideration, then we must complete the expedited reconsideration and give you, and the physician involved notice of its reconsideration as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request.

If Fidelis Care denies a request for an expedited reconsideration, it must automatically transfer the request to the standard reconsideration process and then make its determination as expeditiously as the enrollee’s health condition requires, but no later than within 30 calendar days from the date the Medicare health plan received the request for expedited reconsideration.

This occurs when your or your doctor may submit a request for an authorization or request for services are denied before the services are rendered. You can call our Member Services Department or by fax to: 716-393-6779.

An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. Your, Your Physician or Authorized Representative should call or fax Member Services.