| SNiP Tips
Solving Problems I: Complaints and Appeals
If your client has a problem with the plan, he or she can go through the plan's
complaint and appeal process, the Medicaid fair hearing process, or both. A plan
can't penalize an enrollee for filing a complaint or asking for a fair hearing.
(See also page 20, "Solving Problems II: Fair Hearings.")
| SNiP Tip: For help with appeals or fair hearings,
you or your client can contact the Managed Care Consumer Assistance
Program at GMHC at 212/367-1125; TTY: 212/367-1199.
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How can my client file a complaint?
A complaint is any concern the enrollee tells the plan about.
Complaints are sometimes called grievances. Complaints can be made
at any time about any concern with the HIV SNP, its benefits, employees, or providers.
Examples include rude treatment at the PCP's office and denials of benefits.
An important example of when your client might want to file a complaint is when
he or she gets a notice of a negative decision from the plan. Whenever the HIV SNP
denies your client a referral, denies or reduces benefits or services, or decides
that a requested benefit isn't covered by the plan, the plan is supposed to give
written notice to the enrollee. The notice has to tell your client how to make verbal
and written complaints and the information that the plan will need to make a decision.
If your client is concerned about a referral or a plan-covered benefit, he or she
can make a complaint over the phone. The plan has to have a toll-free number for this,
and has to tell your client.
All other complaints have to be in writing. If your client wants to make a written
complaint, he or she can either write a letter or use a form supplied by the plan.
If your client makes a complaint by phone and the plan solves the problem to your
client's satisfaction right away, the plan does not have to send anything in the mail
to your client.
If the complaint isn't resolved over the phone, the plan has to resolve the complaint
within the following time frames:
- Within 24 hours if a delay would "significantly increase" the risk to the enrollee's
health
- Within 15 days after getting all necessary information for cases about non-urgent
referrals or benefits
- Within 30 days of the receipt of all necessary information for all other cases
In all non-urgent cases, the plan has to send the enrollee written notice of the
complaint within 15 days of getting it. They also have to send contact information
for the person handling the complaint.
The plan's written response about the complaint has to explain:
- The decision
- Procedures for filing an appeal, including forms
- Fair hearing rights (See page 20, "Solving Problems II: Fair Hearings.")
- The enrollee's option to contact the State Department of Health (DOH)
If your client does decide to complain to the New York State Department of Health, he
or she can call 1-800-206-8125 or write to:
NYS Department of Health
Bureau of Certification and Surveillance, Corning Tower
Albany, NY 12237
| SNiP Tip: If your clients make complaints in writing,
advise them to keep a copy of everything sent, and to mail everything "return
receipt requested." If they make a complaint by phone, advise them to keep
notes on the conversation, including what they said, who they talked to, and
the date and time. Also, advise your clients to keep all mail they get from
the plan about the complaint and any appeals.
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How can my client appeal a plan's decision?
If your client isn't satisfied with the plan's decision about the complaint, he or
she has 60 days to file an appeal. An appeal is made by writing a
letter or using a form provided by the plan. Advise your client to keep a copy of the
appeal and to send it "return receipt requested."
The HIV SNP has to send written acknowledgement of the appeal within 15 days, including
how to contact the person handling the appeal. The SNP also has to say what additional
information it needs to make a decision. The plan has to decide on the appeal and inform
the enrollee of the outcome within the following time frames:
- Within one day if a delay would significantly increase the risk to an enrollee's
health; or
- In all other cases, within 30 days of getting all necessary information.
Once the plan makes a decision, it will send a notice to your client. The notice will
include the reasons for the appeal determination, the medical explanation, a notice on
fair hearing rights (if applicable), the right to contact the New York State Department
of Health with the complaint, and information on how to further appeal.
What if the plan says a treatment isn't "medically necessary"?
If the plan says that a treatment or service your client wants isn't "medically
necessary," your client can ask for a utilization review. The process
is similar to an appeals process.
Enrollees with life-threatening or disabling conditions or diseases, like HIV, can
also ask for an external appeal when one or more covered services have
been denied as experimental or investigational. All enrollees can ask for an external
appeal if services were denied as not medically necessary. An external appeal can be
requested after the enrollee has been denied under the initial internal utilization
review procedure or when both the enrollee and plan agree to skip the internal
procedure. However, an external appeal must be filed before the internal utilization
review procedure has been completed.
An external appeal has to be filed within 45 days of the final negative decision
from the plan. To get an application for an external appeal, contact the New York
State Department of Insurance at 1-800-400-8882 or www.ins.state.ny.us, or call the plan's
member services hotline.
| SNiP Tip: Your clients can name someone else to
represent them in an appeal process if they are not comfortable dealing
with the process themselves. This can be a friend, family member, or advocate.
The plan can tell your client how to name a representative for this purpose.
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