FIDA FAQ

Re: Non–Participating Provider Appeals

  • FAQs also available in Portable Document Format (PDF)

1. Is there a typo in the document titled "Non–Par Appeal Rights Summary". On the bottom of p. 1? Should it say "Non–Participating Provider" instead of "Participant".

A. Yes, the language should read "For decisions not wholly in the Non–Participating Provider's favor, the notification must inform the Non–Participating Provider that such adverse decision will be automatically forwarded to the Integrated Administrative Hearing Office at OTDA." We have re–issued the Summary.

2. Please clarify how long the plan has to resolve an Out–of–Network (OON) provider claim appeal. The model notice templates indicate 60 calendar days, however the Appeal Rights and Summary indicates 30 calendar days.

A. The requirement is that the FIDA Plan 60 days for reimbursement requests and 30 days for all other appeals. We have corrected this error in the re–issued Summary. The days are counted from the date the appeal request is received.

3. Are plans required to submit the required notices through HPMS for review?

A. No.

4. Can a FIDA Plan dismiss a non–participating provider appeal if the non–participating provider does not submit the waiver of liability?

A. In the event that a non–participating provider files a request for appeal but the non–participating provider does not submit the waiver of liability, the FIDA plan must make, and document, its reasonable efforts to secure the waiver of liability form. If after 60 days for reimbursement request or 30 days for all other appeals from the date of the appeal being filed by the non–participating provider, the non–participating provider does not provide the waiver, the FIDA plan can dismiss the appeal. Again, the FIDA plan need not review until a signed waiver of liability form has been received. The 60–day or 30–day clock to review the appeal starts when the waiver is received.

5. If the FIDA Plan dismisses the appeal for failure to submit a waiver of liability after waiting 30 days, can the non–participating provider appeal again?

A. The non–participating provider may appeal a second time and, if the deadline for appealing the plan's decision has not yet lapsed, the FIDA Plan must accept the 2nd appeal. If the deadline has passed, the FIDA Plan must apply the good cause policy to decide whether to accept the 2nd appeal.

6. Is there a dismissal letter template?

A. Yes. We have disseminated a dismissal letter template for plans to use if and when necessary.

7. When FIDA Plans auto–forward a Non–Participating Provider appeal to the IAHO, does the plan also send it to the IRE simultaneously based on the FHIS code list?

A. Yes.

8. Can the FIDA Plan just send the Non–Participating Provider Appeal Rights Summary with an Explanation of Payment?

A. FIDA Plans must send an ICDN to providers when denying a requested service or request for payment. As per the Non–Participating Provider Appeals policy issued 11/29/16, FIDA Plans must send the Non–Participating Provider Appeal Rights Summary with the required ICDN. The Summary must be sent with the ICDN. The FIDA Plan may also send the Summary with the EOP. The Plan may send the Summary, ICDN, and Explanation of Payment all together.

9. Can a Non–Participating Provider request an expedited appeal?

A. No.

10. The new Appeals Rights and Process Summary indicates "When a Non–Participating Provider receives a denial or partial denial of a claim, the Non–Participating Provider may file a 1st Level Appeal (with the FIDA Plan)." Partially denied claims typically fall into one of three buckets: corrected claim required; payment amount dispute; or an appeal. Please confirm that this is applicable to only appeals, and not the other 2 categories.

A. Yes. This is only applicable to appeals and not to payment amount disputes or corrections of claims.

11. In reference to the model WOL template, is the "Claim ID Number" required; can plans remove this from their template? Providers typically reference the most recently denied claim to meet the appeal filing deadline although there are instances where the same claim was previously submitted and denied. Is the Claim ID Number mandatory?

A. Yes, Plans may remove this. Including this is optional.

12. Several of the notices contain information about appointing a representative and we believe that this is not necessary to be included on this type of letter.

A. Non–Participating providers may appoint someone to represent them. Nonetheless, we modified the notice language slightly. Appeal notice #1 was revised to remove reference to the CMS 1696 form.

13. Letters were issued with the Non–Par Provider Appeals guidance in November 2016, will model letters be issued for Par (Participating) Provider Appeals as well, or should the plan continue to use the member notices when a Par Provider requests an appeal?

A. The notices issued with the guidance are for use with Non–Participating Providers when they are filing on their own behalf. When Non–Participating Providers or Participating Providers file on behalf of a Participant, Plans should continue to use the Participant notices. Participating Providers are not permitted to file an appeal on their own behalf.

14. What is the correct mailing address for OTDA?

A. In the fall we corrected the contact info for OTDA:

MAILING ADRESS: FIDA Integrated Administrative Hearings Office P.O. Box 1930 Albany, New York 12201
PHYSICAL ADDRESS: 14 Boerum Place, Brooklyn, New York 11201

FAX: 518–473–8783