• Appeals

  • There are several levels of appeal available to you if you disagree with Affinity’s decision to not approve a requested service. These levels are called Appeal, Fair Hearing, and External Review.

    When Affinity makes a decision to not approve a requested service, Affinity will issue you a letter called “Initial Adverse Determination” and explain the reason why. You may file an Appeal if you disagree with the Initial Adverse Determination. Affinity will gather the necessary information to review your Appeal, and the decision will be made by a different clinical peer reviewer that the one who made the first decision. There are certain steps to filing an appeal and the timeframes for handling appeals will vary according to the type of appeal.

  • Categories

    Pre-service Appeal

    This is a service you are requesting which you are not currently receiving, and which Affinity did not approve. This category also includes the decision by Affinity to not approve a service from an Out-of-Network provider when that service is available to you from a Network provider.

    How to Communicate with Affinity for your Pre-service Appeal

    To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing. If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.

    If you are providing a written appeal, include the reason you are making the appeal, and include any documents that may help in the research of your case. Send the appeal request to:

    Affinity Health Plan
    A&G Unit- Quality Management Department
    Metro Center Atrium
    1776 Eastchester Road
    Bronx, NY 10461

    You may also fax your appeal to 718.536.3385, “Attention Appeals and Grievances Unit”

    You may also ask for an appeal by calling us for free at:

    888.543.9069
    Monday through Sunday, 8:00 am to 8:00 pm
    TTY: 711

    Timeframe for Appealing Affinity’s Pre-service Initial Adverse Determination

    Affinity will complete their review of your appeal and issue a written determination within 30 calendar days of receipt of all needed information. If Affinity decides to uphold the Initial Adverse Determination, you will receive a letter titled, “Final Adverse Determination” along with instructions for the next level of appeal, should you wish to take that step.

    Concurrent Appeal

    This is a service you are currently receiving which Affinity has made a decision to reduce, suspend, or discontinue.

    Concurrent Appeal with Aid to Continue

    When you are receiving previously approved services such as home health assistance, private duty nursing, or long-term support services, and Affinity has made a decision to deny, reduce, suspend, or stop that service, you are also eligible to file an Appeal with Aid to Continue. You must indicate this to Affinity within 10 days of receiving the Initial Adverse Determination. Under the Appeal with Aid to Continue category, your services will continue without interruption while your appeal is being reviewed.

    How to Communicate with Affinity for your Concurrent Appeal

    To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing. If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.

    If you are providing a written appeal, include the reason you are making the appeal, and include any documents that may help in the research of your case. Send the appeal request to:

    Affinity Health Plan
    A&G Unit- Quality Management Department
    Metro Center Atrium
    1776 Eastchester Road
    Bronx, NY 10461

    You may also fax your appeal to 718.536.3385, “Attention Appeals and Grievances Unit”

    You may also ask for an appeal by calling us for free at:

    888.543.9069
    Monday through Sunday, 8:00 am to 8:00 pm
    TTY: 711

    Timeframe for Appealing Affinity’s Concurrent Initial Adverse Determination

    Affinity will complete their review of your appeal and issue a written determination within 30 calendar days of receipt of all needed information. If Affinity decides to uphold the Initial Adverse Determination, you will receive a letter titled, “Final Adverse Determination” along with instructions for the next level of appeal, should you wish to take that step.

    Expedited Concurrent Appeal

    A concurrent appeal can be handled on an expedited basis when Affinity Health Plan determines or the provider indicates that a delay would seriously jeopardize the member’s life or health, the ability to attain, maintain or regain maximum function or the action was the result of a concurrent review of a service authorization request. An expedited appeal will be reviewed and responded to within 72 hours or receiving the request.

    Post-service Appeal

    This is a service which you have received and completed, but upon review of the submitted medical information, Affinity has made a decision to not approve part or all of the service received. Post-service appeals are not eligible for expedited appeal status.

    How to Communicate with Affinity for your Post-service Appeal

    To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing. If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.

    If you are providing a written appeal, include the reason you are making the appeal, and include any documents that may help in the research of your case. Send the appeal request to:

    Affinity Health Plan
    A&G Unit- Quality Management Department
    Metro Center Atrium
    1776 Eastchester Road
    Bronx, NY 10461

    You may also fax your appeal to 718.536.3385, “Attention Appeals and Grievances Unit”

    You may also ask for an appeal by calling us for free at:

    888.543.9069
    Monday through Sunday, 8:00 am to 8:00 pm
    TTY: 711

    Timeframe for Appealing Affinity’s Concurrent Initial Adverse Determination

    Affinity will complete their review of your appeal and issue a written determination within 30 calendar days of receipt of all needed information. If Affinity decides to uphold the Initial Adverse Determination, you will receive a letter titled, “Final Adverse Determination” along with instructions for the next level of appeal, should you wish to take that step.

  • Pharmacy Appeals

  • Once Affinity notifies you of a decision regarding a coverage determination request, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Similar to coverage determinations, there is a fast track and routine process for handling appeals.

    You have a right to appeal if you think Affinity:

    • Decided not to cover a drug, vaccine, or other Part D benefit
    • Decided not to reimburse you for a Part D drug that you paid for
    • Reimbursed you less than you feel you should have received
    • Asked you to pay a different cost-sharing amount than you think you are
    • Required to pay for a prescription
    • Denied your exception request

    We will consider your appeal thoroughly and promptly. The time frames listed above will give you an idea of when you can expect a response from Affinity. It is important to let us know as soon as possible that you wish to file an appeal. If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination.

    You may fax your Appeal request to 866.633.7673 or mail it to the following address:

    CVS Caremark Inc
    Part D Services
    MC109
    P.O. Box 52000
    Phoenix, AZ 85072-2000

    To request a fast appeal, you may call 866.362.4002, 24 hours a day, seven days a week. TTY users can call 711.

    If your complaint is regarding a quality of care issue (for example, you believe our pharmacist provided you with the incorrect dose of a prescription) you may also file a complaint with the Quality Improvement Organization (QIO), called Island Peer Review Organization (IPRO) by calling 800.331.7767 or for TTY, 866.446.3507. A QIO is a group of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Quality Improvement Organization review process is designed to help stop any improper medical practices.

    Who May Ask for a Grievance or an Appeal?

    You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form (English | Spanish) and send it to us with your request. You can call us at 877.234.4499 or for TTY at 711 if you need help filling out the form or want to learn more about appointing a representative.