Grievance and Appeal Contacts for Managed Long Term Care Plans

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.

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 mltctac@health.ny.gov
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, 2^nd 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: Empire BlueCross BlueShield HealthPlus 9 Pine Street, 14^th Floor New York, NY 10005 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)	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	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 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 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
UnitedHealthcare Personal Assist	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

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.