File A Complaint: Grievance

Available to members of managed care organizations only.

Anytime you have a complaint or a problem with your MCO you have a grievance and can file a formal grievance to get your MCO to change its decision. Grievances can be about anything, for example, if you think you had to wait too long to get an appointment with a HCP or if you feel you were treated badly by a HCP. The grievance procedures are used in cases where the MCO decides that your complaint or problem is not a question of medical necessity. The law sets up the way your MCO must handle your grievance.

Your MCO must tell you how to file a grievance any time it denies a request for a referral or decides that it won’t pay for a service or treatment that you or your HCP asked for. It must also tell you how to file a grievance in its member handbook. If the denial is based on medical necessity, your MCO must tell you how to use the UR procedures.

When an MCO refuses to pay for care or denies you a referral that you and/or your HCP feel you need, the MCO must tell you how to file a grievance. This is called A Notice of Grievance. It has to include:

  • A description of the grievance process.
  • How to file a grievance.
  • How long each part of the grievance process takes.
  • Your right to pick someone to help you (your representative).
  • How to use the grievance process if you have trouble communicating in English.

You can file your grievance by telephone when:

Your MCO or your HCP denies you a referral to a treatment, test or service you and/or your HCP think you need: for example, a referral to a specialist.
Your MCO decides it won’t pay for a benefit you think it should pay for.

For these types of grievances, your MCO must have a toll free grievance phone number, answered by real people, 5 days a week, during normal business hours. After hours, the MCO must have a way for you to leave a message (voice mail, answering machine, etc.) and the MCO must return your call within 1 business day. For example, if you leave a message on Wednesday night, the MCO has to call you back on Thursday.

Your MCO may ask you to sign a written acknowledgment of your grievance which the MCO sends you. The acknowledgment will describe your complaint. You should read this carefully and change your MCO’s description of your complaint if it’s not accurate. Your MCO will not start to process your complaint until you sign and return this acknowledgment unless waiting for you to return the
acknowledgment would increase the risk to your health.

Some grievances must be filed in writing:

Other than denials of referrals or benefits, your MCO may ask you to file a grievance in writing; for example, if you are complaining about the length of time you had to wait to get an appointment with a HCP. In these cases, your MCO will ask you either to write a letter or to fill out a form that the MCO will supply. After your MCO receives your letter or completed form, your MCO must tell you what information they need in order to make a decision.

How the grievance process works:

Your MCO must send you a written notice that they received your grievance within 15 days of the date they received it. This notice must include the name, address and phone number of the person(s) or department that will make the decision about your grievance. The decision will be made by one or more qualified people who work for your MCO. If your grievance involves a health question, one of these people must be a licensed, certified or registered health care professional.

How long does the decision process take?

Within 48 hours after you call and reported your grievance by phone, and after the receipt of all necessary information, if a delay in their decision would significantly increase the risk to your health, the MCO must call you on the phone with their decision. Your MCO has to follow that up in writing within 3 business days. This is called an expedited decision.

Within 30 days after you returned the signed acknowledgment your MCO provided and all necessary information has been supplied, when a delay would not increase the risk to your health and your grievance is about the MCO denying you a referral or refusing to pay for a benefit.

Within 45 days in writing in all other cases, such as billing problems.

The MCO’s written decision about your complaint is called a Grievance Determination. It must include:

  • The reasons for the decision.
  • If it’s a medical matter, the medical basis for the decision.
  • How to appeal if you disagree.
  • The forms you’ll need to file an appeal.

You have the right to appeal a Grievance Determination

You can appeal your MCO’s decision. Don’t give up! Sometimes MCOs change a decision because a person has shown how seriously she/he takes the problem by filing an appeal.

Your MCO must give you at least 60 days to appeal. All appeals are in writing (by letter or by a form the MCO supplies); you cannot appeal orally.

Once you send your MCO an appeal, your MCO has 15 days to send you a written acknowledgment that the MCO received your appeal. This written acknowledgment must include:

The name, address and phone number of the person(s) deciding your appeal. This cannot be the same person who decided your grievance. In health questions, this person or people must be health care professionals, including at least one person who has expertise in that particular health field. If it’s not a health question, then the appeal person has to be a higher level staff person than the one who originally decided against you.

Any other information the MCO needs to make its decision.

How long does the appeal process take?

Within 2 business days the MCO must tell you its decision, if a delay would significantly increase the risk to your health.

Within 30 days in writing, in all other cases.

The MCOs written decision about your appeal is called an Appeals Notice. It must include the reasons for the decision, and, if it’s a medical matter, the medical basis for the decision.

Your right to complain to New York State:

At any time, before, during or after you have gone through your MCO’s grievance and appeals processes, you can file a complaint with the State Department of Health Managed Care Hot-Line: 800-206-8125 for complaints about the quality of your care, or with the State Insurance
Department Consumer Services Bureau: 800-342-3736
for problems about payment for benefits, or with the Attorney General’s Health Care Bureau: 1-800-771-7755.

Remember, you can file a complaint with the Department of Health, the Insurance Department or the Attorney General’s Health Care Bureau at any point in the processes described in this guide and anytime you have a problem with your plan.

Tell your MCO that you know you can file a complaint with the State. This may encourage your MCO to consider your appeal carefully. The law says that MCOs cannot punish you or your HCP or anyone who advocates for you for filing a grievance or an appeal.

Records of grievances

Your MCO must keep a record of every grievance filed, including: the dates grievances and appeals were filed, the decisions and the dates they were made, the titles of the people who
made the decisions and their credentials.

MCOs must report yearly to the State Health Department the number of grievances each has dealt with. In these reports information must be kept confidential that might identify you.

Every year The New York State Insurance Department compiles a report on complaints made about health insurance plans called The Annual Health Insurance Complaint Rankings. You can get a copy from: The New York State Insurance Department, Office of Public Affairs, 160
Broadway, New York, NY 10013, 212-602-0428.

If you request it, your MCO must tell you how many grievances it has received each year. It must also tell you how many of the grievances it decided in the enrollees favor. The number of grievances filed with an MCO can help you decide which MCO you may want to join.