Grievances and Appeals

Your health and satisfaction are important to us. When you have a problem or concern, please call RiverSpring FIDA Plan first at 1-800-950-9000. Our participant service staff will work with you to try to find a satisfactory solution to your problem.

You can also contact us to ask about the grievance and appeals process, or a status update on the processing of your grievance or appeal. For information on the total number of grievances, appeals and exceptions filed with RiverSpring FIDA Plan, please contact

RiverSpring FIDA Plan Appeals
80 West 225th Street
Bronx, New York 10463
1-800-950-9000.
Fax Number: 1-888-341-5009

For more information, see the Participant Handbook

Grievances

A grievance is a complaint that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies.

If you need to file a grievance with directly with Medicare, please fill out the Medicare Complaint Form

Appeals

An appeal is a way for you to challenge a coverage decision if you think it is wrong. You can ask RiverSpring FIDA Plan to change a coverage decision by filing an appeal.

Appointment of representative

If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.”

The Appointment of Representative form must be signed by you and by the person whom you would like to act on your behalf.

You or your appointed representative can file a grievance or appeal by calling or writing to us.

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by RiverSpring FIDA Plan. ICAN may be reached toll free at 1-844-614-8800 or online at http://www.icannys.org (Clicking on this link will take you away from the RiverSpring FIDA Plan website.)

Please follow the link for the Notice of nondiscrimination and Accessibility Requirements

How to Request a Coverage Determination for Medical Care

How to request coverage for medical care?

When requesting coverage for medical care it is referred to a request for an organization determination. An organization determination, also known as a service authorization, is the plans initial decision about whether we will provide the medical care or service a participant requests, or pay for a service a participant has received.

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want at the contact information listed below. You, your doctor, or your representative can do this.

Call: 1-800-950-9000 8 a.m. – 8 p.m., 7 days a week TTY: 711 Fax: 1-866-889-3292 Or,

Write:

RiverSpring Health Plans
80 West 225 Street
Bronx, N.Y. 10463

Timeframes For Filing An Organization Determination:

Expedited Organization Determination: Notification of a decision will be given as quickly as the participant’s health condition requires but no later than 72 hours of receiving the request. RiverSpring may extend the timeframe by up to 14 calendar days if the member requests the extension or if we need additional information and the extension of the time benefits you.

Standard Organization Determination: Notification of a decision will be given as quickly as the participant’s health condition requires but no later than 14 calendar days of receiving the request. RiverSpring may extend the timeframe by up to 14 calendar days if the participant requests an extension or RiverSpring may grant itself an extension if it is in the best interest of the participant.

Claim Organization Determinations: Notification of a decision will be made within 30 calendar days for claims from non-contracted providers and all other claims within 60 calendar days.

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This page was last updated on June 6, 2018 2:30:00 EST