NY Manual
SHP Manual

New York Provider Manual
15.13 External Review – Medicaid, FHPlus | 15.15 Standard Appeals – Commercial, CHPlus

15.14 Member Complaints – Medicaid

If a member has a problem, he/she can speak with his/her PCP or call or write to Member Services. Most problems can be solved right away. If a member has a problem or dispute with the care he/she is receiving, he/she can file a complaint with Healthfirst. Problems that are not solved right away over the phone and any complaint received via mail will be handled according to our complaint procedure described below.

Members can ask someone they trust (such as a legal representative, a family member, or friend) to file the complaint for them. If a member needs help because of a hearing or vision impairment or if he/she needs translation services or help filing the forms, we can help. Healthfirst will not take any action against the member for filing a complaint.

A member also has the right to file a complaint with the local area office of the New York State Department of Health or local Department of Social Services. To file with the New York State Department of Health, members may call 1-800-206-8125 or write to NYSDOH Division of Managed Care, Bureau of Managed Care Certification and Surveillance, Corning Tower ESP Room 1911, Albany, NY 12237.

To file with the City of New York, members may call the Human Resources Administration, Medicaid Assistance Program Helpline at 1-800-505-5678.

A member may also contact their local Department of Social Services with their complaint at any time. A member may call the State Department of Financial Services at 1-800-342-3736 if their complaint involves a billing problem.   

How to File a Complaint with the Plan

To file by phone, a member can call Member Services at 1-866-463-6743. If a member calls Healthfirst after hours, they can leave a message and Healthfirst will return the call the next working day. If we need more information to make a decision, we will inform the member.

A member can write to us with a complaint or call the Member Services number and request a complaint form, which should be mailed to Healthfirst Appeals & Grievances Department, P.O. Box 5166, New York, NY 10274-5166 or faxed to 1-646-313-4618.

What Happens Next?

If we don’t solve the member’s problem right away over the phone, we will send him/her a letter within fifteen (15) business days. The letter will tell the member who is working on the complaint, how to contact this individual, and whether more information is needed.

A member’s complaint will be reviewed by one (1) or more qualified people. If the complaint involves clinical matters, the case will be reviewed by one or more qualified healthcare professionals.

After We Review the Complaint

We will let the member know our decision within forty-five (45) calendar days of when we have all the information we need to answer the complaint, but the member will hear from us within no more than sixty (60) calendar days from the day we get the original complaint. We will write the member and will tell him/her the reasons for our decision.

When a delay would risk the member’s health, we will let the member know of our decision within forty-eight (48) hours of when we have all the information we need to answer the complaint, but the member will hear from us within no more than seven (7) days from the day we get the original complaint. We will call the member with our decision or try to reach the member to tell him/her. The member will get a letter to follow up on our communication within three (3) business days.

The member will be told how to appeal our decision if he/she is not satisfied, and we will include any forms needed. If we are unable to make a decision about a member’s complaint because we don’t have enough information, we will send a letter to let the member know.

Appeal of Complaints

If a member disagrees with a decision we made about his/her complaint, he/she can make a complaint appeal personally or ask someone they trust to file the appeal for them. If a member is not satisfied with what we decide, he/she has sixty (60) business days after hearing from us to file an appeal, which must be in writing. After a member calls, we will send a form which is a summary of their phone appeal.

What Happens After We Receive the Member’s Complaint Appeal?

After we get a member’s complaint appeal, we will send him/her a letter within fifteen (15) business days. The letter will tell him/her who is working on the complaint, how to contact this individual, and whether more information is needed.

The complaint appeal will be reviewed by one (1) or more qualified people at a higher level than those who made the first decision about the complaint. If the complaint appeal involves clinical matters, the case will be reviewed by one (1) or more qualified health professionals, with at least one (1) clinical peer reviewer who was not involved in making the first decision about the complaint.

If we have all the information we need, the member will know our decision in thirty (30) business days. If a delay would risk his/her health, he/she will get our decision within two (2) working days of when we have all the information we need to decide the appeal. The member will be given the reasons for our decision and our clinical rationale, if it applies. If the member is still not satisfied, he/she or someone on their behalf can file a complaint at any time with the New York State Department of Health at 1-800-206-8125.