Appeals and Grievances

We encourage you to let us know right away if you have questions, concerns, or problems related to your QHPNY coverage. Members should call Customer Services at 1-877-233-7058 or TTY/TDD 711.

Federal law guarantees your right to make a complaint by filing a Appeal or a Grievance if you have concerns or problems with any part of your care as a plan member. The Medicare Health Plan program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from your plan or penalized in any way if you make a complaint.

A complaint will be handled as either an Appeal or a Grievance depending on the subject of the complaint.
An Appeal is a formal way of asking us to review and change a decision we have made about what benefits are covered for you or what we will pay for a medical procedure or treatment.
A Grievance is any complaint related to the quality of care you receive from the health plan and its networked providers other than those that involve a Part C Organizational Determination (Part C plan benefits and treatment) or Part D Coverage Determination (Part D drug benefits and medication).

Appeals

An appeal is the action you can take if you disagree with a coverage or payment decision made by Quality Health Plans of New York. You have the right to appeal any decision about your services. You can appeal if Quality Health Plans of New York denies:

  • A request for a health care service, supply, or prescription that you think you should be able to get
  • A request for payment for health care services or supplies or a prescription drug you already got that was denied
  • A request to change the amount you must pay for a prescription drug

You can also appeal if Quality Health Plans of New York stops providing or paying for all or part of an item or service you think you still need.

For a complete explanation of the Appeals process, please refer to Chapter 9: What to do if you have a problem or complaint of your plan’s Evidence of Coverage document. Enrollees and physicians who have questions about or seeking status of a grievance, coverage determination or appeal processes should contact us using the below Customer Service phone numbers.

Grievances

You would file a grievance if you have any type of problem with our plan or one of our network providers that does not relate to coverage for a treatment or prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

We will notify you of our decision within 30 days of receipt of the written grievance. Additional time may be required if we justify the need for additional information and the delay is in your best interest.

For a complete explanation of the Grievances filing process, please refer to Chapter 9: What to do if you have a problem or complaint of your plan’s Evidence of Coverage document.

Filing an Appeal or a Grievance
To request an Appeal or Grievance you may:
Call to make an oral request – see contact information below.
Fax or mail a written request – see the contact and mailing information below.
Click HERE to access the Request for Redetermination (Appeal) of Medicare Prescription Drug Denial form.
Click HERE to send a request via a SECURE electronic web message

CONTACT US

  • PHONE Call Toll Free
  • 1-877-233-7058
  • Customer Service
  • TTY: 711
  • M-F, 8:00am – 8:00pm ET
  • FAX Toll Free Facsimile Service
  • 1-877-738-4870
  • Perfect for Fast-Track Appeals
  • Secure and Confidential
  • All Types of Complaints Accepted
  • WRITE Plan Home Office
  • Write or Visit
  • Quality Health Plans of New York
  • Appeals & Grievances Department
  • 2805 Veterans Memorial Highway, Suite 17
  • Ronkonkoma, NY 11779

You can also use the information above to obtain an aggregate number of grievances, appeals and exceptions filed with QHPNY. You may find a statement of your rights and responsibilities and this plan’s rights and responsibilities in your Evidence of Coverage document.

 

Appointing a Representative

You can ask someone to act on your behalf. If you want to, you can name a friend, relative, your doctor or other provider, or other person to act for you as your “representative” to file an Appeal or a Grievance. If you would like to appoint a representative please complete the below CMS Appointment of Representation form and return to Quality Health Plans of New York by using the contact information listed above. The form must be signed by you and by the person who you would like to act on your behalf.

CMS Appointment of Representation Form (Form-CMS-1696)