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Complaints and Appeals

• Managed Long-Term Care
• External Appeals
• Managed Care Bill of Rights

Contact Your Plan

If you are dissatisfied with your plan or any of its employees, providers, or contractors, or your plan's services, determination of benefits, or the health care treatment received through the plan, you can file a complaint or grievance with your plan. You may make your complaint/grievance verbally or in writing. You may also designate someone to make the complaint/grievance for you.

Refer to your member handbook to learn how to use the plan's complaint/grievance process or call the plan's member services or complaint/grievance phone line listed on your health plan identification card. Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances. Many issues can be resolved with a phone call to your plan.

Contact Government Agencies

Managed care enrollees and providers can file a complaint with certain government agencies. Depending on the type of health care plan involved and the kind of complaint, there are different agencies that can help. You do not have to file a complaint with your plan before you speak with or write to a government office.

The office you contact may ask you to complete a form to file your complaint. If you make a verbal complaint, you may be asked to send written information or documents to support your complaint. If you designate someone to make the complaint for you, you may be asked to sign a written authorization form to allow the government to share your personal health care information with your designee.

Once all needed information is received, the agency will review or investigate the complaint. The agency may work with the health care plan to correct the problem, and may check if any laws or regulations were violated. The agency will inform you of how the complaint was resolved.

To file a complaint, find your issue on the chart below and contact the government agency listed through the phone number, web site or mailing address provided.

List of government agency complaint contacts

Who	Issue	Call	Write
Anyone enrolled in a NYS certified MCO	dissatisfaction with quality of health care difficulty getting appointments denied referrals difficulty getting the health care or type of doctor needed billing concerns or plan's refusal to pay or a covered service	(800) 206-8125	NYS Department of Health Bureau of Managed Care Certification and Surveillance Complaint Unit Room 1911 Corning Tower ESP Albany, NY 12237-0062
Anyone	cost of insurance policy health care coverage questions complaint against any insurance company	(800) 342-3736 New York City: (212) 480-4701	Consumer Services Bureau NYS Insurance Department One Commerce Plaza Albany, NY 12257 Consumer Services Bureau NYS Insurance Department 25 Beaver Street New York, NY 10004-2319 Fax: (212) 480-6282
Anyone	Health care complaints	(800) 771-7755 (Option 3) TDD (800) 788-9898	NYS Office of the Attorney General - Health Care Bureau The Capitol Albany, NY 12224-0341 Fax: (518) 402-2163
NY Medicaid managed care enrollee	eligibility questions enrollment issues concern about the plan's marketing practices	Local Department of Social Services	Local Department of Social Services
NY Medicaid managed care enrollee	Fair Hearing request	Office of Temporary and Disability Assistance	Fair Hearing Section NYS Office of Temporary and Disability Assistance PO Box 22023 Albany, NY 12201-2023 Fax: (518) 473-6735
Anyone enrolled in a NY Managed Long Term Care	dissatisfaction with health care difficulty getting health care needed	(800) 206-8125	NYS Department of Health Bureau of Continuing Care Initiatives 161 Delaware Avenue Delmar, NY 12054
Anyone receiving services from a Workers' Compensation PPO	dissatisfaction with the Workers' Compensation PPO	(518) 474-5514	NYS Department of Health Workers' Compensation Programs Room 2001 Corning Tower ESP Albany, NY 12237-0094
NY health care providers	termination issues delivery of medical care concerns access and availability	(800) 206-8125	NYS Department of Health Bureau of Managed Care Certification and Surveillance Complaint Unit Room 1911 Corning Tower ESP Albany, NY 12237-0062
NY health care providers	late payments by a plan prompt payment law	(800) 358-9260	NYS Insurance Department One Commerce Plaza Albany, NY 12257 Fax: (518) 474-2188
Medicare recipients	dissatisfaction with quality of care in NYS appeals and grievances	IPRO, (800) 331-7767	Branch Chief, Health Plan Branch Centers for Medicare and Medicaid Services Federal Building 26 Federal Plaza, Room 3811 New York, New York 10278 (212) 264-3657
Anyone enrolled in a self-insured/ ERISA plan or through COBRA	Benefit claims appeals information	1-866-444-3272	Eastern NY and NYC: Employee Benefits Security Administration U.S. Department of Labor New York Regional Office 33 Whitehall Street, Suite 1200 New York, NY 10004 Fax: (212) 607-8681 Central and Western NY: Employee Benefits Security Administration U.S. Department of Labor Boston Regional Office J.F.K. Building, Room 575 Boston, MA 02203 Fax: (617) 565-9666