MRT 101 - Develop initiatives to integrate and manage care for eligible duals

FIDA Program Notices

• FIDA Region 2 Consumer Notice Letter
• FIDA Program Announcement Letter for (eligible Kings County (Brooklyn) residents
• FIDA Program Announcement Letter for eligible Nassau county residents
• 60–day notice
• 30–day notice
• All other FIDA notices
  • FIDA Non–Participating Provider Appeals Guidance
    1. Non–Participating Provider Appeal Rights and Process Summary
    2. FIDA Integrated Appeals Case File Cover Note (PDF)
    3. Acknowledgement of Appeal (PDF)
    4. Non–Participating Provider Appeals Notice – Approved (PDF)
    5. Non–Participating Provider Appeal Decision Notice – Denied (PDF)
    6. Non–Participating Provider Provider Notice of Appeal Decision – Delay (PDF)
    7. Non–Participating Provider Request for Additional Information (PDF)
    8. Non–Participating Provider Acknowledgement of Auto–Forward of Appeal (PDF)
    9. Waiver of Liability Statement for Appeal by FIDA Non–Participating Provider (PDF)
    10. Dismissal Notice (for failure to submit required Waiver of Liability) (PDF)
  • Reporting Requirements for measures 7.1 and 7.2
  • Voluntary Enrollment Pended – Missing Information Notice
  • Voluntary Enrollment Pended – Employer, Union, or Retiree Member Notice
  • Voluntary Enrollment Denial Notice
  • Opt–Out Confirmation and Cancellation of Enrollment from MLTC or FFS to FIDA Confirmation Notice
  • Disenrollment Cancellation and Reinstatement Notice - Confirmation of Continued FIDA Plan Enrollment
  • Safe Discharge Confirmation Form (PDF, 223KB)
  • Managed Care Transfer Request Confirmation Notice
  • Voluntary Disenrollment Confirmation Notice with Notice of Safe Discharge Transfer to MLTC
  • Voluntary Disenrollment Confirmation Notice
  • Voluntary Disenrollment Denial Notice #1
  • Voluntary Disenrollment Denial Notice #2
  • Involuntary Disenrollment Confirmation Notice
    • Involuntary disenrollment form (PDF, 62KB)
    • Voluntary disenrollment (safe discharge) form (PDF, KB)
  • Integrated Coverage Determination Notice (ICDN)
    • Instructions for ICDN Models
    • ICDN Model 1
    • ICDN Model 2
    • ICDN Model 3
  • Integrated Appeal Model Notices
    • Acknowledgement of Appeal
    • Expedited Appeal Request Denial
    • In-Person Appeal Review
    • Appeal Decision Notice - In Favor
    • Appeal Decision Notice - Adverse
    • Acknowledgement of Auto-Forward of Appeal
    • Notice of Appeal Decision Extension
    • Request for Additional Information
  • Model Grievance Notices
    • Grievance Decision
    • Notice of Grievance Decision Extension