Service Authorization and Appeals

For Mainstream Medicaid Managed Care Plans, HARP, and HIV SNP

  • 42 CFR 438 MMC Service Authorization and Appeals - MMC/HIV SNP/HARP
  • 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
  • Supplemental Final Rule FAQs - (Web) - (PDF) - revised February 7, 2018
  • New York State Medicaid Managed Care Enrollee Right to Fair Hearing and Aid Continuing for Plan Service Authorization Determinations - (Web) - (PDF)
  • New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison -- (Web) - (PDF)
  • New York State Medicaid Managed Care Grievances Timeframe Chart - (Web) - (PDF)

DOH Model Notices for Mainstream Medicaid Managed Care Plans, HARP, and HIV SNP

Medicaid managed care plans are required to submit templates for these notice types to the Department for approval prior to use. Templates will only be accepted from the health plan and must include a unique identifier on each page. A completed and signed cover sheet must accompany each template submitted. Submit templates and cover sheets to: bigaplans@health.ny.gov.

  • Template Notice Submission Cover Sheet - (Web) - (PDF) - 11.4.2021
  • 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
    • Denial Notice - (Web) - (PDF) - 11.4.2021
    • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021
  • Initial Adverse Determination
    • Denial Notice - (Web) - (PDF) - 11.4.2021
    • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021
  • Approval Notice - (Web) - (PDF) - 11.20.2017

Contact bigaplans@health.ny.gov for any questions on this page.