The Departmental Appeals Board has partnered with CMS and the State of New York to adjudicate appeals stemming from the Fully Integrated Duals Advantage (FIDA) demonstration project. The FIDA project will replace the parallel system of separate Medicare and Medicaid appeals for dually-eligible beneficiaries with one single unified system in a targeted geographic area of New York. This will provide beneficiaries with a fully-integrated Medicare and Medicaid appeals process that includes the most consumer-friendly elements of the Medicare and Medicaid processes.
The appeals system will have four levels of appeal for all non-Part D covered services. First, if a FIDA health plan denies a claim, the beneficiary may request an internal review by the plan. The plan will apply both Medicare and Medicaid coverage criteria to determine if it should cover the claim. If the plan again denies the claim, the beneficiary’s request will be automatically forwarded to the FIDA Administrative Hearing Unit at the New York Office of Temporary and Disability Assistance (OTDA) for a review and hearing. OTDA will apply both Medicare and Medicaid coverage rules in its review of the appeal. If OTDA upholds a plan’s denial of a claim, beneficiaries will have the option to appeal to the Medicare Appeals Council (MAC) for further review. As with OTDA, the MAC will review the denial of any FIDA plan-covered claim and will apply both Medicare and Medicaid coverage rules. The MAC’s decision can then be appealed to federal court.
This unified appeals system aims to reduce beneficiary confusion, speed access to appropriate services, and generate administrative savings by eliminating the need to pursue multiple appeals for the same claim. For more information on the FIDA demonstration project, please visit CMS's website.