Integrated Coverage Determination Notice (ICDN)

Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under "Get help & more information." Oral interpretation is available for all languages. Acess this service by calling [phone number].

[FIDA PLAN NAME/LOGO]

Appeal Level: 1

APPEAL DECISION NOTICE

Name:                                                   Date of Notice:

Participant Number:

[Insert other identifying information, as necessary (e.g., provider name, Participant´s Medicaid number, service subject to notice, date of service)]

Dear [Participant name],

[Plan name] reviewed your appeal, received on [date appeal received, orally or in writing] [for expedited appeals insert: at {hour received}] about the following action: [Insert a detailed description of the FIDA Plan action/IDT decision (e.g. denial, reduction, PCSP renewal, etc.) being appealed and the benefits involved (provide more detail than the Appeal Acknowledgement letter). Also, include the original rationale for the FIDA Plan action/IDT decision that is the basis of the Participant´s appeal.]




Level 1 Appeal decision

The appeal was decided in your favor on [date of appeal decision]. That means we [Insert as applicable: reversed or modified] the previous decision made on [date of plan coverage determination or PCSP update, as applicable].

What this means

Because our Level 1 Appeal decision is fully in your favor, you are authorized to receive the following services as of [date authorized (no later than one business day after the FIDA Plan appeal decision date)]: [List the services that were approved, including any applicable information about coverage amount, duration, etc.]




If you do not receive the services, or if the services are wrongly stopped or reduced, tell us immediately using the contact information below:

[Plan name]
[Name of Appeals/Grievance Department]
[Mailing Address for Appeals/Grievance Department]

Phone: [phone number] TTY: [TTY number]
Fax: [fax number]

You can also contact the Independent Consumer Advocacy Network (ICAN) to help you resolve the issue. Call ICAN at 1-844-614-8800. TTY users call 711, then follow the prompts to dial 844-614-8800.

Getting your case file

You can ask to see the medical records and other documents we reviewed during your appeal. You can also ask for a copy of the guidelines we used to make our decision. You or your representative (if you have one) may request these documents, at no cost, by calling [phone number] or by fax to [fax number].

[Plans must send a copy of this notice to relevant parties (e.g. representative, designated caregiver, etc.) and include the following text:]

A copy of this notice has been sent to:

[name]
[address]
[phone number]

Get help & more information

(TTY users call 711, then use the phone numbers below)

  • [Plan name]
    Toll Free Phone: [phone number]
    TTY users call: [TTY number]
    [hours of operation]

  • Independent Consumer Advocacy Network (ICAN)
    Toll Free Phone: 1-844- 614-8800
    8:00am - 8:00pm, Monday - Sunday

  • Elder Care Locator
    Toll Free Phone: 1-800-677-1116

  • 1-800-MEDICARE (1-800-633-4227)
    TTY users call: 1-877-486-2048
    24 hours a day, 7 days a week

  • NYS Department of Health
    Toll Free Phone: 1-866-712-7197

  • Medicare Rights Center
    Toll Free Phone: 1-888-HMO-9050

[Plan´s legal or marketing name] is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

You can get this information for free in other languages. Call [toll-free number] and [TTY/TDD numbers] during [hours of operation]. The call is free. [This disclaimer must be in English and all non-English languages that meet the Medicare or State thresholds for translation, whichever is most beneficiary friendly. The non-English disclaimer must be placed below the English version and in the same font size as the English version.]

You can also ask for this information in other formats, such as Braille or large print.

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 [plan name]. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.