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].

[Plan Name/Logo]

GRIEVANCE 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 grievance (also called a "complaint"), received on [date grievance received, orally or in writing], about the following issues: [Describe the Participant´s grievance.]




Grievance investigation

We took the following steps to review your grievance: [Explain the steps taken by the plan in accordance with the NYSDOH and CMS approved grievance process.]






What we found

Based on our review, we made the following decision regarding your grievance: [Inform the Participant of the results of the investigation. Provide specific rationale for the decision and describe any corrective action the plan intends to take. Include citation to relevant federal or state law or plan policy, where applicable, to support the decision. Include any clinical rationale, if any, and indicate that the Participant or their representative may request the relevant clinical review criteria at no cost to them.]






What happens next?

If you are satisfied with the outcome of our decision, you do not need to do anything else.

If you are not satisfied with our decision, you or your representative (if you have one) may file an external grievance.

How to file an external grievance

An external grievance is filed with and reviewed by an organization that is not connected to [plan name]. There are two ways to file an external grievance:

  • You can tell Medicare about your grievance. You can use the Medicare Complaint Form available online at: https://www.medicare.gov/MedicareComplaintForm/home.aspx. Or, you can call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • You can tell the New York State Department of Health (NYSDOH) about your grievance. To file a grievance with NYSDOH, call the Helpline at 1-866-712-7197.

If you file a grievance with Medicare or NYSDOH, your grievance will be sent to the Medicare and Medicaid team overseeing [plan name] and the FIDA Program. They will review your grievance and follow up with you and your representative (if you have one).

If you need help filing an external grievance, you can call the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. TTY users call 711, then follow prompts to dial 844-614-8800.

Other options for filing a grievance

If your grievance involves disability access, language assistance, or quality of care, there are also other organizations that can help:

  • You can file grievances about disability access or language assistance with the Office of Civil Rights. Call the Office of Civil Rights at [phone number for the OCR regional office]. You may also have rights under the Americans with Disabilities Act. Contact the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800 for assistance.
  • You can file grievances about quality of care to the Quality Improvement Organization (QIO). The phone number for the QIO is 1-866-815-5440.

If you want someone to represent you

You can have someone else represent you during your appeal. You can choose anyone to represent you, like a family member, friend, doctor, attorney, or an ICAN staff member (see below).

If you already named someone to represent you when you requested this appeal, or if you have someone who is otherwise able to act for you because he or she is a legal guardian, power of attorney, or otherwise authorized to make health care decisions on your behalf, you do not have to do anything else.

If you have not already named someone to represent you and want to choose someone now, both you and the person you want to act for you must sign and date a statement confirming this is what you want. You can write a letter or use the Appointment of Representative form available at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Send your letter or form to us by fax or mail. If you have any questions about naming your representative, such as what to say in your letter, contact IAHO using the information above or call us at: [phone number]. TTY users call [TTY number].

The state created the Independent Consumer Advocacy Network (ICAN) to help you with appeals and other issues with the FIDA program. ICAN is independent, and the services are available to you for free. They can help answer your questions about the appeals process, give you advice, and may even represent you. Call ICAN at 1-844-614-8800. TTY users call 711, then follow the prompts to dial 844-614-8800.

[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.