Service Authorization, Appeals, and Notices
For Medicaid Managed Long Term Care Plans
Medicaid Advantage Plus (MAP) Integrated Notices
MAP plans are required to submit templates for certain integrated notices to the Department for approval prior to use. Templates will only be accepted from the health plan and must include the plan's unique identifier on each page. A completed and signed coversheet must accompany each template submitted. Submit templates and coversheets to: mltc.docs@health.ny.gov
Model Notices
Model Notices for Medicaid Managed Long Term Care Plans (Partial and MAP)
Managed Long Term Care plans are required to submit templates for model notice types to the Department for approval prior to use. Templates will only be accepted from the health plan and must include the plan's unique identifier on each page. A completed and signed cover sheet must accompany each template submitted. Submit templates and cover sheets to: mltc.docs@health.ny.gov
- Model Notice Submission Coversheet - (PDF) - 1.2.2024
- Complaint Appeal Resolution Notice - (Web) - (PDF) - 11.4.2021
- Complaint Resolution Notice - (Web) - (PDF) - 11.4.2021
- Extension Notice - (Web) - (PDF) - 11.4.2021
- Final Adverse Determination
- Initial Adverse Determination
- Approval Notice - (Web) - (PDF) - 11.20.2017
Template Notices
Guidance for Health Plans
- Reasonable Effort Policy - (Web) - (PDF) - 4.17.23
- Guidance for Required Changes to Medicaid Model Notices About Service Authorization and Appeals under 42 CFR 438 - (Web) - (PDF) - November 4, 2021
- 2016 Final Rule FAQs About Service Authorization and Appeals under 42 CFR 438 - (Web) - (PDF) - January
- New York State Medicaid Managed Long Term Care Enrollee Right to Fair Hearing and Aid Continuing for Plan Service Authorization Determinations
- New York State Medicaid Managed Long Term Care Service Authorization and Appeals Timeframe Comparison
- New York State Medicaid Managed Long Term Care Grievances Timeframe Chart
Webinars
- 42 CFR 438 MMC Service Authorization and Appeals - Partial, MAP, MA
- Presentation - December 7, 2017
Contact mltc.docs@health.ny.gov for any questions on this page.
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