FIDA Non-Participating Provider Appeals Guidance: 11/29/16

To:       FIDA Plans

From: Joseph Shunk

Re:     FIDA Non–Participating Provider Appeals

Date:  November 29, 2016

Effective immediately, FIDA Non–Participating Provider Appeals will be heard through the FIDA Integrated Appeals Process. Participating Provider Appeals will not use the FIDA Integrated Appeals Process but will use the mechanism outlined in Participating Provider contracts. The Three–Way Contract is being revised to reflect this.

Participating and Non–Participating Providers can continue to use the Integrated Appeals Process when they are filing an appeal on behalf of a Participant. This is unchanged.

We have made this change because in Medicare Non–Participating Providers have a right to appeal. This right has carried over to FIDA but has not been part of the Integrated Appeal Process. CMS and NYSDOH felt that in this joint Medicare–Medicaid demonstration, this right needs to be available on the Medicaid side as well.

In order to appeal through the Integrated Appeal Process, Non–Participating Providers will need to submit their appeal to the FIDA Plan following the steps and timelines of the Integrated Appeal Process. They will need to complete the FIDA Waiver of Liability Form and send it along with their appeal. The statement in this form mirrors the Medicare "waiver of liability" statement: "I hereby waive any right to collect payment from [name of Participant], the Participant, for the aforementioned services for which payment has been denied by the above–referenced health plan. I understand that the signing of this waiver does not negate my right to request further appeal under Medicare rules." FIDA Plans should include a blank FIDA Waiver of Liability Form when informing Non–Participating Providers of their appeal rights.

Attached are templates of Appeal Notices that would be sent to Non–Participating Providers:

  1. FIDA Non–Participating Provider Appeal Rights and Process Summary. *NEW* – This document must be sent with every complete or partial denial of payment for a claim by a Non–Participating Provider.
  2. FIDA Waiver of Liability Form *NEW*
  3. Non–Par Provider Appeal Acknowledgement – A1NPP – *Revised version of Participant Notice A1.
  4. Non–Par Provider Approval – A4NPP – *Revised version of Participant Notice A4.
  5. Non–Par Provider Denial – A5NPP – *Revised version of Participant Notice A5.
  6. Non–Par Provider Auto–forward – A6NPP – *Revised version of Participant Notice A6.
  7. Non–Par Provider Extension – A7NPP – *Revised version of Participant Notice A7.
  8. Non–Par Provider Add'l Information – A8NPP – *Revised version of Participant Notice A8.

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