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Exceptions and Appeals

Exceptions and Appeals Resources

Enrollee Grievance and Appeal Procedures (PDF)
This is a summary of our grievance, coverage determination and appeals processes. If you would like to know the number of grievances and appeals that have been filed with HIP, please call Customer Service.

HIP Medicare HMO Part D Redetermination Request Form (PDF)
Providers may use this form to submit a second level redetermination request for a member by fax. This includes instructions for completing the form as well as where to submit it.

Medicare Prescription Drug Coverage Determination and Exception Request Form (PDF)
This includes instructions for completing the form as well as where to submit it. Providers and Members may use this HIP form, the CMS form (below), or submit the request in writing.

CMS Coverage Determination and Exception Request Form (PDF)
Providers and Members may use the HIP form (above), this CMS form, or submit the request in writing.

How to Appoint a Representative
You may ask us for a coverage determination yourself, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative. This statement must be sent to us at HIP Health Plan of New York 55 Water Street New York, New York 10041-8190 Attn: Customer Service Dept. You can call Customer Service to learn how to name your appointed representative.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

View CMS's Appointment of Representative Form (PDF).

 

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