NY Health Access About Us   |   Contact Us Empire Justice Center Legal Aid Society NYLAG WNYLC

Grievance and Appeal Contacts for Managed Long Term Care Plans

print  Print
share  Share
Views: 9205
Posted: 08 Oct, 2012
by --
Updated: 22 May, 2015
by Amanda Gallipeau (Empire Justice Center)

Selfhelp has assembled this list of appeal and grievance contacts and policies to aid consumers and advocates in exercising their rights. The list was created using documents received in January 2013 from a FOIL request submitted to the NYS Department of Health and a review of managed long term care plan websites.  It will be updated as more information becomes available.

A good starting point is referring to your plan's member handbook, which each enrollee should receive at the beginning of enrollment with a plan.   If the member handbook is posted online, we have included the link in the list below, as it will provide important background on how to submit an appeal or grievance.  We will be posting PDFs of member handbooks in the chart below if they are not available online.  (Please e-mail us a PDF of your plan's member handbook if you don't see it in our chart!)  

An enrollee 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 enrollee 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 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 enrollee believes she should have, 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). 

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

IN ADDITION TO FILING A GRIEVANCE OR APPEAL WITH THE PLAN - ALSO COMPLAIN TO THE STATE --

State Complaint Number for MLTC Problems - 1-866-712-7197 

  • 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 Information Grievance Information Phone Member handbook
Aetna Better Health

Online information on appealing adverse actions can be found here.

855-456-9126 Member handbook can be downloaded here.
Agewell Online information on how to appeal an adverse action can be found here. 866-586-8044 Member handbook can be downloaded here.
Archcare Community Life 855-467-9351 Member handbook can be downloaded here. Available in English and Spanish.

Centerlight Healthcare Select MLTC

Corporate Policy - MLTC - Appeals from Adverse Determinations, dated Jan. 19, 2006. Corporate Policy - MLTC - Grievance Procedure, dated Jan. 19, 2006. 877-226-8500 Member information available here.
Centers Plan for Healthy Living Online information on appealing adverse actions can be found here. Online information on the grievance process available here. 855-270-1600 Upstate and downstate member handbooks available here.
ElderServe Health Inc. Corporate Policy - MLTC - Appeals from Adverse Determinations, undated. Corporate Policy - MLTC - Grievance Procedure, undated. 800-370-3600
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, last revised August 22, 2011.  Grievance information begins on p. 1. 800-688-7422 Member handbook available here.
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.

800-932-4703
HealthPlus MLTC (Amerigroup) Corporate Policy - MLTC  - Appeals of Adverse Determinations, last revised March 24 , 2011  Corporate Policy - MLTC - Grievance Procedure, last revised Dec. 28, 2011. 800-950-7679 Member handbook and other information available in English and Spanish.

HHH Choices Health Plan LLC (Co-op Care Plan)

Corporate Policy - MLTC - Appeals of Adverse Determinations, dated April 11, 2005. Corporate Policy - MLTC - Grievance Procedure, dated April 5, 2006 718-678-1600 or 866-745-8111
HIP/Emblem MLTC Appeals and Grievance info here. 888-447-9161 Member handbook available here.
HomeFirst, Inc. MLTC Information on appeals available in Member Handbook at page 28 and in FAQ on website. Information on grievances available in Member Handbook at page 28 and in FAQ on website.

877-771-1119

Member information and handbook available here.
Independence Care System

212-584-2596/27 or 877-427-2525.               Fax 212-584-2555. Member handbook available in English and Spanish.
MetroPlus Appeals and Grievance info starts on page 19 of the member handbook. 855-355-6582               Fax 212-908-5282 Member handbook available in English and Spanish.
Senior Health Partners (Healthfirst Company) 866-585-9280
Senior Whole Health of New York - MLTC 877-353-0185 Member handbook available here.

UnitedHealthcare Personal Assist

Member handbook discusses appeal and grievance process beginning page 30.

855-345-6582 Member handbook available in English and Spanish.

VillageCare Max Member handbook discusses appeal and grievance process beginning page 29.

800-469-6292

Member handbook available here.
VNSNY Choice MLTC

Member handbook discusses appeal and grievance process beginning page 58.

855-282-4642

Member handbook available here.
WellCare Advocate MLTC Appeals information available here. 877-395-4282 Member handbook available here.

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. 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
Guildnet Gold, Inc. 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 Amerigroup Appeals of Adverse Determinations - MLTC - NY.pdf (103 kb) Download
item CCM Select Appeals policy APPROVED.pdf (45 kb) Download
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 HHH Choices MLTC Service Authorization Action Appeals.pdf (167 kb) Download
item HHH Choices MLTC Grievance policy.pdf (97 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 - Consumer Rights
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

Prev     Next
Delays in Processing of Medicaid Applications - What are Your...       Court Orders Lifting Restrictions in Medicaid Coverage for...


This site provides general information only. This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelpny.org. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information. To report a dead link or other website-related problem, please e-mail us.