Extension Notice

MODEL MLTC/MMC EXTENSION NOTICE (Revised 11/17)
FOR SERVICE AUTHORIZATION REQUESTS OR APPEALS

  • Notice also available in Portable Document Format (PDF)

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MCO/MLTC OR DUAL LETTERHEAD FOR PLAN AND UR AGENT/BENEFIT MANAGER]
[Plan Name] [UR AGENT/Benefit Manager Name]
[Address]
[Phone]

REVIEW EXTENDED

[Date]

Enrollee]
[Address]
[City, State Zip]

Enrollee Number: [ID number or CIN]
Coverage type: [insert coverage type]
Service: [describe requested or claimed service including: amount/duration/date of service]
Provider: [requesting provider]
Plan Reference Number: [plan reference number]

Dear [Enrollee]:

On [Date of Request] you [asked [Plan Name] for [service]] {or} [asked for a Plan Appeal about [service]]. [[UR Agent Name] on behalf of] [Insert Plan Name] is reviewing your request. You are getting this notice because we need more information and are extending our review until [Date].

We feel this is best for you because: [explanation of how the delay is in the best interest of the Enrollee].

To review this request, we need the following information: [Additional information required]

If this information is not received by [Date] we will make a decision based on the information we have.

Please mail or fax the requested information to:

[Contact Name]
[Plan/UR Agent Name]
[Address]
[City, State Zip
]
Fax: [1–800–MCO PLAN]

[{Insert when extension is for an appeal} [If we do not make a decision by [EXPDate], you may ask the State for a Fair Hearing. You can call 1–800–342–3334 or fill out the form online to ask for a Fair Hearing.]

If you disagree with our decision to extend review of your [request][Plan Appeal], you or your designee may file a complaint by calling [1–800–MCO PLAN] or writing to [Plan/UR Agent Address]. A decision will be made within 45 days after receipt of all necessary information but no more than 60 days from receipt of the complaint.

Other Help:

You can file a complaint about your managed care at any time with the New York State Department of Health by calling [{for MMC}[1–800–206–8125] {or for MLTC} [1–866–712–7197

{Insert for MLTC/LTSS/HARP Services or Delete}[You can call the Independent Consumer Advocacy Network (ICAN) to get free, independent advice about your coverage, complaints, and appeals´ options. They can help you manage the appeal process. Contact ICAN to learn more about their services:

Phone: 1–844–614–8800 (TTY Relay Service: 711)
Web: www.icannys.org | Email: ican@cssny.org]]

You can call [PLAN NAME] at [1–800–MCO–PLAN] if you have any questions about this notice. {Insert as applicable} [To talk to someone at [Insert UR Agent] call [Insert UR Agent Number].]

Sincerely,

[MCO/UR AGENT/BENEFIT MANAGER Representative]

cc:    Requesting Provider
         {Insert as applicable} [Enrollee Representative(s)]


NOTICE OF NON–DISCRIMINATION

[PLAN NAME] complies with Federal civil rights laws. [PLAN NAME] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

[PLAN NAME] provides the following:

  • Free aids and services to people with disabilities to help you communicate with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Free language services to people whose first language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, call [PLAN NAME] at <toll free number>. For TTY/TDD services, call <TTY>.

If you believe that [PLAN NAME] has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with [PLAN NAME] by:

Mail:             [ADDRESS], [CITY], [STATE] [ZIP CODE],
Phone:        [PHONE NUMBER] (for TTY/TDD services, call <TTY>)
Fax:              [FAX NUMBER]
In person:   [ADDRESS], [CITY], [STATE] [ZIP CODE]
Email:         [EMAIL ADDRESS]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by:

Web:              Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail:               U.S. Department of Health and Human Services
                       200 Independence Avenue SW., Room 509F, HHH Building
                       Washington, DC 20201
                       Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone:          1–800–368–1019 (TTY/TDD 800–537–7697)

ATTENTION: Language assistance services, free of charge, are available to you. Call <toll free number> <TTY/TDD>. English
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al <toll free number> <TTY/TDD>. Spanish
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 <toll free number> <TTY/TDD>. Chinese
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم toll free numberوالبكم الصم هاتف رقم<TTY/TDD>. Arabic
주의 : 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다<toll free number> <TTY/TDD> 번으로 전화해 주십시오. Korean
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <toll free number> (телетайп: TTY/TDD). Russian
ATTENZIONE: In caso la lingua parlata sia l´italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero <toll free number> <TTY/TDD>. Italian
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le <toll free number> <TTY/TDD>. French
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele <toll free number> <TTY/TDD>. French Creole
אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון .toll free number/TTY/TDD< רופט .אפצאל Yiddish
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer <toll free number> <TTY/TDD> Polish
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa <toll free number/TTY/TDD>. Tagalog
লক্ষ ্য করুনঃ যদি আপদন বাাংলা , কথা বলতে পাতেন , োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে । ফ ান করুন ১ -<toll free number> <TTY/TDD> Bengali
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në <toll free number> <TTY/TDD>. Albanian
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε <toll free number> <TTY/TDD>. Greek
ںیرک لاک ۔ ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںیہ ےتلوب ودرا پآ رگا :رادربخ <toll free number> <TTY>. Urdu