NYSDOH/CMS Policy for Late FIDA Integrated Appeal Requests ("Good Cause Policy")

• Policy is also available in Portable Document Format (PDF)

This document outlines the requirements for FIDA Plans to follow when a FIDA participant or Non–Participating Provider requests an appeal after the initial level 1 filing deadline.

In accordance with Section 2.13.1.1.2.1 of the Three–way Contract, the deadline to request a level 1 appeal is 60 days after a FIDA Plan sends the notice of action. Plans have the discretion to waive this deadline, and treat the appeal as if it was filed timely. If a Plan waives the deadline, the rest of the appeal should be processed normally, in accordance with Section 2.13 of the Three–way Contract and any relevant State or federal rules, regulations, and guidance materials. NYSDOH and CMS advise FIDA Plans to exercise reasonable judgment in deciding whether or not to waive the deadline. If a FIDA Plan declines to waive the deadline, it must adhere to the following procedures.

When an appeal is requested after the deadline, the normal appeal process applies, except as indicated:

• In the Acknowledgement of Appeal, FIDA Plans should include a statement in the first free–form text field to indicate: a) that the appeal is late, b) that the FIDA Plan will determine whether there is good cause for it being late, and c) that the appellant should contact the FIDA Plan to explain why he/she filed late, if he or she has not already done so.
• FIDA Plans must rule on the issue of timeliness by deciding whether the Participant or Non–Participating Provider has "good cause" for filing late. FIDA Plans must exercise their best judgment in determining what constitutes good cause based on the facts of each case. For a non–exclusive list of examples of good cause, see Section 70.3, Chapter 13 of the Medicare Managed Care Manual.
• If a FIDA Plan finds good cause, it must rule on the underlying issue(s) of the appeal. If the FIDA Plan makes an adverse determination on the underlying issue(s), the Appeal Decision Notice should include a statement verifying the good cause finding. The statement should be made at the end of the first free–form text field. No explanation is required for a good cause finding.
• If a FIDA Plan finds no good cause, it must issue an appeal decision accordingly–using the Appeal Decision Notice. A finding of no good cause is treated like a reason for denial. The FIDA Plan should indicate the finding of no good cause in the Level 1 Appeal decision section of the Appeal Decision Notice, and provide an explanation that is commensurate with the facts of the case, and the level of evidence and explanation provided by the participant. Once decided, the FIDA Plan auto–forwards the case to IAHO as under the normal appeal process. If IAHO finds good cause, it may remand the case back to the FIDA Plan.