Prior authorizations and actions
Certain medications and services may need approval from Senior Whole Health of New York before they’re covered. This is called a prior authorization. Prior authorization is usually required if you need a complex treatment or prescription. Since coverage will not be authorized without it, beginning the prior authorization process early is important. Ask your doctor if a prescription drug or treatment is going to require prior authorization so they can start the process.
For more information about the prior authorization process, please review your Senior Whole Health of New York Member Handbook.
How do I file a complaint or appeal?
We understand there may be times when you aren’t completely happy or satisfied. We try our best to deal with your concerns or issues as quickly as possible and to your satisfaction. You may use either our complaint (grievance) process or our appeal process, depending on what kind of problem you have.
If you choose to authorize a representative, complete and return the Appointment of Representative Form.
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A complaint is any communication by you to us of dissatisfaction about the care and treatment you receive from our staff or providers of covered services. For example, if someone was rude to you or you do not like the quality of care or services you have received from us, you can file a complaint with us.
You may file a complaint over the phone or in writing.
• To complain by phone, call (877) 353-0185
• To file a complaint in writing, send a letter to:
Senior Whole Health of New York
15 MetroTech Center, 11th Floor
Brooklyn, NY 11201
You may also contact the New York State Department of Health anytime for filing complaints by calling them at (866) 712-7197 or writing to them at:
Bureau of Managed Long Term Care
New York State Department of Health
Corning Tower Room 1911
Empire State Plaza
Albany, NY 12237
If you do not agree with an action that we have taken, you may appeal. When you file an appeal, it means that we must look again at the reason for our action to decide if we were correct. You can file an appeal of an action with the plan orally or in writing.
To file an appeal by phone, call Senior Whole Health of New York Member Services at (877) 353-0185 (TTY/TDD: 711).
To file an appeal in writing, send a letter to:
Senior Whole Health of New York
Attn: Quality Improvement Department
15 MetroTech Center, 11th Floor
Brooklyn, New York 11201
Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get a benefit or money. Fraud is intentional with knowledge that the information is false.
Waste is when someone overuses health services carelessly. Waste isn’t always intentional.
Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.
Providers:
• Providing medical services that are not needed
• “Up-coding” – charging for a more complex or expensive service than was given
• Billing for services that were not provided
• Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
• Billing for rented medical equipment after it has been returned
• Billing twice for the same service
• Billing for more services than can be performed in one day
• Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a
patient to refer other Medicaid members, or to get services that are not needed)
Members:
• Using another person’s name to get Medicaid services
• Sharing a member ID card or using another person’s member ID card
• Visiting several doctors to get multiple prescriptions
• Lying to a care coordinator or someone else to try and get a service you don’t need
• Paying a doctor cash for a prescription that is not needed
• Making false documents by changing:
• The date of service
• Prescriptions
• Medical records
• Referral forms
Reporting suspected fraud, waste and abuse is easy— and it’s important.
AlertLine: (866) 606-3889
Online reporting: https://molinahealthcare.alertline.com
Other ways to report suspected fraud:
Office of Inspector General (OIG)
To report suspected cases of fraud, waste, or abuse in Federal Health and Human Services (HHS) programs, you may fill out the online OIG Hotline form. You can also call, mail or fax using the information below:
Office of Inspector General
U.S. Department of Health & Human Services
ATTN: HOTLINE
PO Box 23489
Washington, DC 20026
Phone: (800) HHS-TIPS (8477)
TTY: (800) 377-4950
Fax: (800) 223-8164
Centers for Medicare and Medicaid Services
(800) MEDICARE / (800) 633-4227
- You may also send your concerns by mail to:
Attention: Compliance Officer
(CONFIDENTIAL)
Molina Healthcare of New York, Inc.
2900 Exterior Street
Suite 202
Bronx, NY 10463
- You can also report to the state:
To report suspected Medicaid fraud and/or abuse in New York state, call New York State Attorney General's Medicaid Fraud Control Unit toll free (800) 771-7751 or complete a Medicaid Fraud and Abuse Comment Form, which is available online at: https://ag.ny.gov/comments-mfcu
How do I request a new ID card?
Once you’re enrolled in Senior Whole Health of New York, you’ll get a member ID card. This card has important information for you and your providers.
Always show your member ID card when you go to a health care provider or pharmacy.
If your member ID card is ever damaged, lost or stolen, call Member Services right away at (877) 353-0185. We will mail you a new card.
How do I follow and use a care plan?
Once you are enrolled in Senior Whole Health of New York, you will work with your care manager on creating your person-centered care plan. Your care plan will include the types of health services that you need and how you will get them. It will also include your goals and preferences.
Together, we work as a team which includes your care manager, your doctor(s) and most importantly you (and a caregiver or family member, if desired). Your care team will work with you to update your care plan when your healthcare needs change, and at least once per year.
How do I enroll in Senior Whole Health of New York?
Enroll Now!
Call (877) 353-0188 (TTY/TDD: 711).
When you call, a Senior Whole Health representative will:
• Speak with you, confidentially, about your health care needs
• Explain how our plans work and help you determine if it’s a good fit for you
• Answer any questions you may have about the plan
Once you’re ready, we’ll put you in contact with New York Medicaid Choice and setup a nurse evaluation and offer a plan of care. If you have not been in a long term care plan for 45 days or longer or you want to join a Medicaid-approved long term care plan for the first time you will also need to have a Conflict-Free Evaluation and Enrollment Center (CFEEC) evaluation. For more information about CFEEC, please visit the New York State Medicaid program’s CFEEC website.
Based on your in-home or virtual visit the assessment nurse will use your comprehensive health assessment to develop a person-centered plan of care based on the assessment of your needs. Once you review and accept your plan of care, you are enrolled in the plan.
How do I renew?
You need to recertify your Medicaid coverage annually. The Human Resources Administration (HRA) or Local Departments of Social Services (LDSS) will send you recertification instructions. You will also receive a reminder in the mail from us. If you need help completing your recertification, please call Member Services at (877) 353-0185.
How do I disenroll in Senior Whole Health of New York?
You can ask to leave SWH of NY at any time for any reason. To request disenrollment, call (877) 353-0185 (TTY/TDD: 711) or you can write to us.
For more information on disenrolling from SWH of NY or transferring to another MLTC plan, please view the disenrollment section to the Member Handbook.
