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Grievance and Appeal Contacts for Managed Long Term Care Plans

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Posted: 08 Oct, 2012
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Updated: 16 May, 2018
by Valerie Bogart (New York Legal Assistance Group)

BEGINNING MARCH 1, 2018, members of Medicaid Managed Care and Managed Long Term Care plans will be required to request an INTERNAL APPEAL within their plan, and wait until the plan decides that appeal before they may request a FAIR HEARING.  This is called the "exhaustion requirement" and is required by federal regulations. Read more about this change here -  Heads Up - Changes Coming in Fair Hearing Rights for MLTC and Managed Care Members - March 2018.

On this web page, we will post the contact information for members to request internal appeals in MLTC plans. This will include phone, e-mail, fax, and regular mail addresses. All of this information should be in the plan's member handbook,  but as of Jan. 29, 2018, the State still has not revised the language in the member's handbook describing the appeal process. Therefore the member handbooks posted on plan websites - links in the table below - do NOT now have the updated information. Members should be receiving revised handbooks by mail before May 1, 2018. We will be posting links to revised member handbooks in the chart when available (Please e-mail us a PDF of your plan's member handbook if you don't see it in our chart!).

An enrolee must use either the plan's appeal or grievance procedures depending on the type of problem presented. 

  • A grievance is an expression of dissatisfaction with the plan. For example, an aide came late, the enrolee was treated rudely or was not called back, a request for services hasn't been processed or responded to. A grievance is not about the scope, amount or type of service that was approved by the plan.

  • An Internal Appeal is a request for a review of an action taken by a plan.  If the MLTC plan denies, reduces, or ends services that the enrolee believes he or she should have, he or she has the right to appeal. For example, the plan reduces personal care services from 12 to 8 hours/day, or denies your request to participate in the Consumer-Directed Personal Assistance Program (CDPAP).  Beginning March 1, 2018, the member MUST request this internal appeal first and wait until it is decided by the plan BEFORE requesting a Fair Hearing.

An overview of Grievances and Appeal rights is available in this article linked here.   

In some cases, in ADDITION TO FILING A GRIEVANCE OR APPEAL WITH THE PLAN, you might ALSO COMPLAIN TO THE STATE --

State Complaint Number for MLTC Problems - 866-712-7197 

  • E-mail mltcworkgroup@health.state.ny.us and put "COMPLAINT" in subject line

  • For enrollment complaints - call NY Medicaid Choice -
    •  1-855-886-0570 (Advocates line)
    •  1-888-401-6582 (Consumers line) 

1.  MLTC Plans Information on Appeals or Grievances  -

PLAN

Appeals & Grievance  Information 

UPDATED as of 04/30/18

Mail / in-person

Address to Request and or File Appeals

Phone/Fax/Email to Request Appeal UPDATED as of 04/30/18
Aetna Better Health

Appeal info  here.

Member handbook  here.

Aetna Better Health
Grievance Systems Manager
55 West 125th Street, Suite 1300
NYC, NY 10027

TEL: 855-456-9126

FAX: 855-264-3822

Agewell

Appeal  info  here.

Member handbook   here.

AgeWell New York
Appeals and Grievances Department
1991 Marcus Avenue. Suite M201
Lake Success, NY 11042

TEL: 866-586-8044

TTY: 800-662-1220

Archcare Community Life Member handbook  here. Appeals & Grievances Department, 33 Irving Place, 11th Floor, New York, NY 10003

TEL: 855-467-9351

FAX: 212‑524‑5163

Catholic Health LIFE Handbook can be found here. 55 Melroy Ave
Lackawanna, NY 14218

TEL: (855) 671-3341

FAX: 716-819-5099

Centers Plan for Healthy Living

Grievance & Appeals Appeal info here  

Where to request appeals here.

Member handbook here (4 languages) (3/2017)

 Centers Plan for Healthy Living Advantage Care HMO
75 Vanderbilt Avenue
Staten Island, NY 10304
Attention: Grievance and Appeals Department

TEL:  855-270-1600 ext 3792

FAX:  347-505-7089

Email: GandA@centersplan.com

Complete Senior Care Nondiscrimination Statement can be found here. Senior Care Plus
10315 Professional Circle
Reno, NV 89521

TEL: (888) 303-4333

FAX: 716-285-8249

Eddy SeniorCare Handbook can be found here. 504 State St
Schenectady, NY
12305

TEL: (518) 382-3290

ElderServe Health Inc.

Corporate Policy - MLTC - Appeals from Adverse Determinations, undated.

Corporate Policy - MLTC - Grievance Procedure, undated.

Quality Department

80 West 225 St, 2nd floor, Bronx, 10463

TEL: 800-370-3600

FAX: 888-341-5009 (To Pamela Baez)

Elderwood Health Plan MLTC Handbook can be found here. Member Services Department Elderwood Health Plan 7 Limestone Drive Williamsville, NY 14221

TEL: 866-843-7526

FAX: 716-568-8378

Erie Niagara d/b/a Kalos Health Member handbook can be found here. 2424 Niagara Falls Blvd. Niagara Falls, NY 14304 TEL: 800-894-2464
Evercare Choice

Member handbook can be found here.

Complaint and Appeals handbook can be found here.

EverCare Choice

Attn: Appeals

31 Cerone Place

Newburgh, NY 12550

TEL: (845) 569-0500
Extended MLTC Member Handbook Effective 5/01/2018 Extended MLTC, LLC, 21 Penn Plaza 360 West 31st Street, Suite 304, New York, NY 10001 ATTN: Membership Services Department.

TEL: 855-299-6492 (Ask for Membership Services Department)

FAX: 718-761-5948

Fallon Health Weinberg MLTC MLTC Manual can be found here, Fallon Health Member Appeals and Grievances
10 Chestnut St. 
Worcester, MA 01608

TEL: 866-882-8185

FAX: 508-755-7393

Fidelis Care at Home

Corporate Policy - MLTC - Appeals from Adverse Determinations, last revised August 22, 2011.  Appeals information begins on p. 8.

Corporate Policy - MLTC - Greivance Procedure, p. 1

Member handbook   here.

Fidelis Care at Home, 95-25 Queens Boulevard, Rego Park, New York 11374

TEL: 800-688-7422

TTY: 800-695-8544

FAX: 716-803-8727

Guildnet MLTC

Corporate Policy - MLTC - Appeals from Adverse Determinations, dated Dec. 21, 2005.

Corporate Policy - MLTC - Grievance Procedure, dated July 2005.

Corporate Policy - MLTC - Appeals of Grievances, dated July 2005.

Guildnet MLTC

250 West 64th Street
New York, NY 10023

TEL: 800-932-4703

Email: gnprovrel@jgb.org

Hamaspik Choice, Inc. Member Handbook can be found here.

Hamaspik CHOICE, Inc.

58 Rt. 59, Suite 1

Monsey, NY 10952

TEL: (855) 552-4642

FAX: 845-503-1501

HealthPlus MLTC (Empire BlueCross Blue Shield)

Corporate Policy - MLTC  - Appeals of Adverse Determinations, last revised March 24 , 2011 

Corporate Policy - MLTC - Grievance Procedure, last revised Dec. 28, 2011.

Grievance and Appeals Empire BlueCross BlueShield HealthPlus P.O. Box 1198 New York, NY 10116

TEL: 800-950-7679

FAX: 866-495-8716

HomeFirst, Inc. MLTC (ElderPlan)

Member Handbook for Appeals and Complaints

Member Handbook - General (English)

Elderplan Attn: Appeals & Grievances Department 745 64th Street, Brooklyn, N.Y. 11220

TEL: 877-771-1119

FAX: 718-765-2027

iCircle Care Member handbook for Complaints and Appeals can be found here. 860 Hard Rd
Webster, NY 14580

TEL: 855-775-3778

FAX: 888-519-2816

Independence Care System

Member handbook available in English and Spanish. (2012)

Director of Advocacy Independence Care System 257 Park Ave. South, 2nd floor New York, N.Y. 10010

TEL: 877-427-2525

FAX: 212-584-2555.

Independent Living for Seniors d/b/a ElderONE Information on services can be found here.
More information about ElderONE can be found here.
2066 Hudson Ave
Rochester, NY 14617
TEL: 585-922-9920
Integra MLTC

Member Handbook English

Member Handbook Appeals and Complaints (05/01/2018)

Member Services Integra MLTC, Inc. 1981 Marcus Avenue, Suite 100 Lake Success, NY 11042 TEL: 855-661-0002
MetroPlus Appeals and Grievance info starts on page 19 of the member handbook - English and Spanish (2014) MetroPlus Health Plan Managed Long Term Care 160 Water Street, 3rd Floor New York, NY 10038

TEL: 800-303-9626          

FAX: 212-908-5282

Montefiore Diamond Care (Bronx) Member Handbook Montefiore Diamond Care Grievances and Appeals Department Box 500 200 Corporate Blvd. South, Suite 200 Yonkers, NY 10701

TEL: 855-556-6683

FAX: 915-457-9516

PACE CNY MLTC Information on services can be found here. 100 Malta Ln
North Syracuse, NY
13212
TEL: (888) 728-7223
Partners Health Plan Member handbook can be found here.

Partners Health Plan Claim Appeals

PO Box 16309

Lubbock, TX 79490
TEL: (855) 747-5483
Prime Health Choice LLC Member handbook can be downloaded here. 3125 Emmons Ave
Brooklyn, NY
11235

TEL: (855) 777-4630

FAX: 718-513-7370

RiverSpring at Home Member Handbook (English) RiverSpring Star, ATTN: Appeals & Grievance Dept. 94 W 225th St. 2nd Floor; Bronx, NY 10463

TEL: 800-580-7000

FAX: 888-810-0215

Senior Health Partners (Healthfirst ) Member Handbook Senior Health Partners Attn: Appeals and Grievances PO Box 5166 New York, NY 10274-5166

TEL: 800-633-9717

FAX: 646-313-4603

Senior Network Health LLC Member Handbook can be found here. 1650 Champlin Ave. Utica, NY 13502

TEL: (888) 355-4764

FAX: 315-735-6027 (Claims Dept.)

FAX: 315-624-4541 (Senior Health)

Senior Whole Health of New York - MLTC

Member handbook available here.

Senior Whole Health of New York Quality Improvement Department
58 Charles Street
Cambridge, MA 02141
TEL: 877-353-0185
Total Senior Care Inc. 519 North Union St
Olean, NY
14760
TEL: (866) 939-8613

UnitedHealthcare Personal Assist

Member handbook  beginning page 30. Spanish. (2014)

UnitedHealthcare Community Plan Attn:

MLTC Appeals and Grievances P.O. Box 31364 Salt Lake City, UT 84131-0364

TEL: 877-512-9354

TEL (Appeals Department): 800-493-4647

FAX:  1-801-994-1082

VillageCare Max Member handbook  beginning page 29.

VillageCareMAX Appeals 112 Charles Street New York, NY 10014

TEL: 800-469-6292

FAX: 212-337-5711

VNA Homecare Options LLC

VNA Homecare Options Appeals

PO Box 11157

Syracuse, NY 13218
TEL: 1-866-783-1444
VNSNY Choice MLTC

Member handbook  beginning page 58.

VNSNY CHOICE
MLTC Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523

TEL: 800-469-6292

Email: grievence.appeals@vnsny.org

WellCare Advocate MLTC Appeals information available here.  Member handbook    here. WellCare Appeals Department
P.O. Box 31384
Tampa, FL 33631-3384

TEL: 877-395-4282

FAX: 866-201-0657

2. Medicaid Advantage Plus (MAP) Information on Appeals or Grievances

Plan Name Appeals Information Grievance Information  Phone Number  Member Handbook and Additional Notes
Elderplan, Inc. Draft Corporate Policy MAP Appeals from Adverse Determinations, no date. Draft Corporate Policy MAP Grievance Procedure, no date. 866-386-9437 Elderplan materials available here.
Emblem Health (formerly Health Insurance Plan HIP)

Online appeal information here.

Appeal rights here.

Grievances Information 888-447-9161
Fidelis Draft Corporate Policy MAP Appeals from Adverse Determinations, dated August 2009.  For Appeals see p. 9. Draft Corporate Policy MAP Grievance Procedure, dated August 2009.  For Grievance see p. 1. 877-533-2404 Fidelis Member Handbook available here.
Guildnet Gold, Inc. Appeals and Grievances Information can be found here. 800-932-4703 or 800-815-0000 Member handbook available here.
HealthFirst Complete Care

Corporate Policy MAP Notice of Action and Appeals, no date.

Corporate Policy MAP Appeals from Adverse Determination, last revised Sept. 2011.

Corporate Policy MAP Grievance Procedure, no date.  Note track changes in document. 888-260-1010
HealthPlus, an Amerigroup Company Corporate Policy MAP Appeals from Adverse Determinations, effective date Feb. 1, 2010. Corporate Policy MAP Grievance Procedure, no date.  Note track changes. 866-805-4589 Member handbook available here.
Senior Whole Health M/M Plus 877-353-0185 Member handbook available here.
VNSNY CHOICE Total 866-597-6674 Member handbook available for download here.
WellCare Advocate Complete 866-661-1232 Evidence of Coverage  available  here.

3. Program for All Inclusive Care for the Elderly (PACE) Information on Appeals or Grievances

Plan Name Appeals Information Grievance Information  Phone Number  Member Handbook and Additional Notes
ArchCare Senior Life 866-263-9083
Centerlight Healthcare PACE 877-226-8500 Member rights listed here.


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
item Healthfirst MAP Adv Determination & Adv Org Determinations 1.pdf (31 kb) Download
item Healthfirst MAP Notice of Action and Appeals.pdf (44 kb) Download
item Amerigroup MAP Appeals of Adverse Determinations .pdf (101 kb) Download
item Fidelis MAP appeals and grievance policy.pdf (85 kb) Download
item Elderplan MAP AppealsDRAFT.pdf (89 kb) Download
item CCM Select Grievance Policy APPROVED.pdf (35 kb) Download
item Elderserve Action and Appeal MLTC.pdf (31 kb) Download
item Elderserve Grievance and Appeal MLTC.pdf (27 kb) Download
item Fidelis Care at Home - MLTC- Grievance & Appeals Policy-rev 8-22-11.pdf (87 kb) Download
item Amerigroup Member Grievances and Grievance Appeals - MLTC - .pdf (125 kb) Download
item GuildNet MLTC Internal Appeals Policy .pdf (36 kb) Download
item GuildNet MLTC Grievance Policy .pdf (47 kb) Download
item GuildNet MLTC Appeals of Grievance Policy .pdf (29 kb) Download
item Amerigroup MA and MAP Complaints Grievance Policy.pdf (124 kb) Download
item Elderplan MAP GrievancesDRAFT.pdf (70 kb) Download
item Healthfirst MAP Complaint- Complaint Appeal for Long term ca.pdf (59 kb) Download

Also read
item Managed Long Term Care
item Tools for Choosing a Medicaid Managed Long Term Care Plan
item Appeals & Grievances in Managed Long Term Care - CHANGES COMING MAY 1, 2018
item KNOW YOUR RIGHTS: Managed Long Term Care and FIDA - Fact Sheets, Live and Recorded Webinars

Also listed in
folder Medicaid -> Home Care
folder Medicaid -> Medicaid Managed Care

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