Many sources of information and assistance are available to members enrolled in NYSHIP. By using these resources to their advantage, members are likely to gain much more satisfaction from their health care plan.
When a member has a question concerning his health care coverage, s/he should first refer to the NYSHIP General Information Booklet, and/or the member contract or certificate of insurance (and any subsequent addendums). Members are responsible for knowing this information. If further assistance is needed, the member should be referred to the agency Health Benefits Administrator (HBA), usually found in the Personnel Office. The HBA can obtain full information concerning a member's enrollment status as well as the eligibility requirements and benefit provisions of all health care plan options. The HBA can also assist employees in resolving any claim problems and in filing an appeal of a claim determination.
The Empire Plan and the HMOs offered to members all have procedures for appeals. In the event an Empire Plan carrier or HMO has determined a medical service or item is not covered, in whole or in part, a review of the determination may be requested using this mechanism. Members should be instructed to retain copies of all correspondence and document telephone conversations related to their appeal.
If the member is not satisfied with the results achieved through the formal appeal process, s/he may contact the PEF Joint Committee on Health Benefits (JCHB), in care of the Health Benefits Specialist, and request the Committee's assistance in pursuing the appeal.
If, after conducting an investigation, the PEF JCHB determines the denial of benefits is questionable and/or the decision regarding the appeal was not adequately explained by the carrier or HMO, the appeal will be brought to the PEF/NYS Joint Labor/Management Health Benefits Committee level for further discussion and resolution.
If, after this administrative avenue of appeal has been exhausted, the member is still not satisfied with the outcome, the NYS Insurance Department or, when an HMO is involved, the NYS Department of Health may be contacted and a consumer complaint filed. This would be considered the last step in the administrative appeal process.
Finally, a member may pursue legal means when all other attempts to resolve the matter have failed.