Member Rights
Your health, safety, and well being are the main concern for the team of dedicated PRIME HEALTH CHOICE, LLC staff who care for you in this program. As a member, you have certain rights that are important for you to understand. Please ask your Care Coordinator to explain these to you if you have any questions.
As a member of PRIME HEALTH CHOICE, LLC:
You have the right to receive medically necessary care.
You have the right to timely access to care and services.
You have the right to privacy about your medical record and when you get treatment.
You have the right to get information on available treatment options and alternatives, presented in a manner and language that you understand.
You have the right to get information in a language that you understand and the right to get oral translation services free of charge.
You have the right to be treated with respect and dignity.
You have the right to request a copy of your medical records and ask that the records be amended or corrected.
You have the right to take part in decisions about your healthcare, including the right to refuse treatment.
You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
You have the right to get care without regard to sex, race, health status, color, age, national origin, sexual orientation, veteran’s status, marital status, or religion.
You have the right to be told where, when, and how to get the services you need from PRIME HEALTH CHOICE, LLC including how you can get benefits from out-of-network providers if PRIME HEALTH CHOICE, LLC does not have the services you need in our network.
You have the right to complain to the New York State Department of Health by calling 1(866)-712-7197 or your local Department of Social Services. You also have the right to use the New York State Fair Hearing system or, in some instances, request a New York State External Appeal.
You have the right to appoint someone to speak for you about your care and treatment.
You have the right to make advance directives and plans about your care. In addition, as a PRIME HEALTH CHOICE, LLC member, you may be receiving care from a home care agency, a hospital, an adult day program, and/ or a nursing home. In each of these settings, you have important rights that the health provider must respect. Please be sure that you understand all of your rights as you continue to receive services from PRIME HEALTH CHOICE, LLC and our provider network.
You can ask for a Plan Appeal, or have someone else ask for you, like a family member, friend, doctor, or lawyer. If you told us before that someone may represent you, that person may ask for the Plan Appeal. If you want someone new to act for you, you and that person must sign and date a statement saying this is what you want. Or, you can both sign and date the attached Plan Appeal Request Form. If you have any questions about choosing someone to act for you, call us at: 1-855-777-4630. TTY users call 1-855-777-4613.
You can also 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:
Independent Consumer Advocacy Network (ICAN)
Community Service Society of New York 633 Third Ave, 10th Floor
New York, NY 10017
Phone: 1-844-614-8800 (TTY Relay Service: 711)
Web: www.icannys.org | Email: ican@cssny.org]
The Community Health Access to Addiction and Mental healthcare Project (CHAMP) is an ombudsman program that can help you with insurance rights and getting coverage for your care. CHAMP can help! Contact:
Community Health Access to Addiction and Mental Healthcare Project (CHAMP)
Community Service Society of New York
633 Third Ave, 10th Floor New York, NY 10017
Phone: 1-888-614-5400 (TTY Relay Service: 711)
Web: https://www.cssny.org/programs
Email: ombuds@oasas.ny.gov
You can call, write or visit us to ask for a Plan Appeal. You or your provider can ask for your Plan Appeal to be fast tracked if you think a delay will cause harm to your health. If you need help, or need a Plan Appeal right away, call us at 1-855-777-4630.
Step 1 – Gather your information.
When you ask for a Plan Appeal, or soon after, you will need to give us:
- Your name and address
- Enrollee number
- Service you asked for and reason(s) for appealing
- Any information that you want us to review, such as medical records, doctors’ letters or other information that explains why you need the service.
- [Insert any specific information needed for the plan to render a decision on appeal.]
To help you prepare for your Plan Appeal, you can ask to see the guidelines, medical records and other documents we used to make this decision. You can ask to see these documents or ask for a free copy by calling 1-855-777-4630.
Step 2 – Send us your Plan Appeal.
{If the plan has different contact information for standard and fast track appeals, plans may replace/revise the contact information below.}
Give us your information and materials by phone, fax or mail:
Phone………………………………………… 1-855-777-4630
Fax………………………………………… 1-718-975-8741
Email………………………………………… ITreyvus@primehealthchoice.com, GBaptiste@primehealthchoice.com
Online………………………………………… www.PrimeHealthChoice.com
Mail………………………………………… 3125 Emmons Avenue Brooklyn, NY 11235
In Person………………………………………… 3125 Emmons Avenue Brooklyn, NY 11235
To send a written Plan Appeal, you may use the attached Appeal Request Form, but it is not required. Keep a copy of everything for your records.
We will tell you we received your Plan Appeal and begin our review. We will let you know if we need any other information from you. If you asked to give us information in person, PRIME HEALTH CHOICE, LLC will contact you (and your representative, if any).
We will send you a free copy of the medical records and any other information we will use to make the appeal decision. If your Plan Appeal is fast tracked, there may be a short time to review this information.
We will send you our decision in writing. If fast tracked, we will also contact you by phone. If you win your Plan Appeal, your service will be covered. If you lose your Plan Appeal, we will send you our Final Adverse Determination. The Final Adverse Determination will explain the reasons for our decision and your appeal rights. If you lose your Plan Appeal, you may request a Fair Hearing and, in some cases, an External Appeal.
Standard – We will give you a written decision as fast as your condition requires but no later than 30 calendar days after we get your appeal.
Fast Track – We will give you a decision on a fast track Plan Appeal within 72 hours after we get your appeal.
Your Plan Appeal will be fast tracked if:
- A delay will seriously risk your health, life, or ability to function;
- Your provider says the appeal needs to be faster;
- You are asking for more of a service you are getting right now;
- You are asking for home care services after you leave the hospital;
- You are asking for more inpatient substance abuse treatment at least 24 hours before you are discharged; or
- You are asking for mental health or substance abuse services that may be related to a court appearance.
If your request for a Fast Track Plan Appeal is denied, we will let you know in writing and will review your appeal in the standard time.
For both Standard and Fast Track – If we need more information about your case, and it is in your best interest, it may take up to 14 days longer to review your Plan Appeal. We will tell you in writing if this happens.
You or your provider may also ask the plan to take up to 14 days longer to review your Plan Appeal.
You have the right to ask the State for a Fair Hearing about this decision after you ask for a Plan Appeal and:
- You receive a Final Adverse Determination. You will have 120 days from the date of the Final Adverse Determination to ask for a Fair Hearing;
OR
- The time for us to decide your Plan Appeal has expired, including any extensions. If you do not receive a response to your Plan Appeal or we do not decide in time, you can ask for a Fair Hearing. To request a Fair Hearing call 1-800-342-3334 or fill out the form online at http://otda.ny.gov/oah/FHReq.asp
You have other appeal rights if your plan said the service was: 1) not medically necessary, 2) experimental or investigational, 3) not different from care you can get in the plan’s network or 4) available from a participating provider who has the correct training and experience to meet your needs.
For these types of decisions, if we do not answer your Plan Appeal on time, the original denial will be reversed.
For these types of decisions, you may be eligible for an External Appeal. An External Appeal is a review of your case by health professionals that do not work for your plan or the State. You may need your doctor’s help to fill out the External Appeal application.
Before you ask for an External Appeal:
- You must file a Plan Appeal and get the plan’s Final Adverse Determination; or
- If you ask for a Fast Track Plan Appeal, you may also ask for a Fast Track External Appeal at the same time; or
- You and your plan may jointly agree to skip the Plan Appeal process and go directly to the External Appeal.
You have 4 months to ask for an External Appeal from when you receive your plan’s Final Adverse Determination, or from when you agreed to skip the Plan Appeal process.
To get an External Appeal application and instructions:
- Call PRIME HEALTH CHOICE, LLC at 1-855-777-4630; or
- Call the New York State Department of Financial Services at 1-800-400-8882; or
- Go on line: www.dfs.ny.gov
The External Appeal decision will be made in 30 days. Fast track decisions are made in 72 hours. The decision will be sent to you in writing. If you ask for an External Appeal and a Fair Hearing, the Fair Hearing decision will be the final decision about your benefits.