Complaints and Appeals

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 (not behavioral health services)
  • 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
  • termination issues
  • delivery of medical care concerns
  • access and availability
1–800–206–8125
NYS Department of Health
Managed Care Complaint Unit
OHIP DHPCO 1CP–1609
Albany, New York 12237
Or Email: managedcarecomplaint@health.ny.gov
Anyone enrolled in a NYS certified MCO with questions or comments related to behavioral health managed care
  • Questions or complaints related to Mental Health programs or services
1–800–597–8481
NYS Department of Health
Email: Behavioral.Health.Complaints@health.ny.gov
Anyone
  • cost of insurance policy
  • health care coverage questions
  • complaint against any insurance company
1–800–342–3736

New York City:
1–212–480–6400
Consumer Assistance Unit
NYS Department of Financial Services
One Commerce Plaza
Albany, NY 12210
Anyone
  • Consumer health–related complaints
  • Consumer health care rights
  • Fraudulent, misleading or deceptive practices
1–800–428–9071
NYS Office of the Attorney General – Health Care Bureau
The Capitol
Albany, NY 12224-0341
Fax: (518) 650–9365
NY Medicaid managed care enrollee
  • eligibility questions
  • enrollment issues
Local Department of Social Services or
NY Health OPTIONS
1–855–693–6765
Local Department of Social Services
NY Medicaid managed care enrollee
  • Fair Hearing request
1–800–342–3334
Fair Hearing Section
NYS Office of Temporary and Disability Assistance

Managed Care Hearing Unit
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
1–866–712–7197
NYS Department of Health
Bureau of Managed Long Term Care
Suite 1620, One Commerce Plaza
99 Washington Ave.
Albany, NY 12210
Anyone receiving services from a Workers´ Compensation PPO
  • dissatisfaction with the Workers´ Compensation PPO
1–518–474–5515
NYS Department of Health
Workers´ Compensation Programs
Room 1609, One Commerce Plaza
99 Washington Ave.
Albany, NY 12210
NY health care providers
  • late payments by a plan
  • prompt payment law
NYS Department of Financial Services
NYS Department of Financial Services
One Commerce Plaza
Albany, NY 12210
Medicare recipients
  • dissatisfaction with quality of care in NYS
  • appeals and grievances
1–866–334–9866
Centers for Medicare and Medicaid Services
Division of Medicare Health Plans Operations
26 Federal Plaza, Room 3810
New York, NY 10278
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

Central and Western NY:

Employee Benefits Security Administration
U.S. Department of Labor
Boston Regional Office
J.F.K. Federal Building, Room 575
Boston, MA 02203