SINCE 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 when they receive an Initial Adverse Determination denying or partially denying a request for services. 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. NOTE: the "exhaustion requirement" does not apply to Fair Hearings regarding Medicaid eligibility.
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. Please let us know any corrections or additions at eflrp@nylag.org
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 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.
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 |
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. |
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 |
CLOSED |
CLOSED |
TEL: 800-932-4703 |
|
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 PO Box 62429, Virginia Beach, VA 23466-2429. Request Evidence Packet: Attn: Grievance and Appeals Department – Physical Health Dept Include member ID and Appeal ID numbers (listed in FAD) |
TEL: 800-950-7679 FAX: 866-495-8716 Evidence Packet Requests Fax No: 888-642-4009 |
|
HomeFirst, Inc. MLTC (ElderPlan) |
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 |
CLOSED (now a health home) |
CLOSED |
TEL: 877-427-2525 |
|
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 Services Integra MLTC, Inc. 1981 Marcus Avenue, Suite 100 Lake Success, NY 11042 |
TEL: 855-661-0002 FAX: 718-368-6267 |
||
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 | ||
CLOSED 9/1/19 |
CLOSED | |||
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: grievance.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 |
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.