Complaints and Appeals

1. What are Complaints and Appeals?
2. How Can I File A Complaint And/or Appeal?
3. The Complaint Process
4. How do I Appeal a Complaint Decision?
5. What is an Action?
6. Timing of Initial Adverse Determination (IAD)
7. Contents of the Initial Adverse Determination (IAD)
8. How do I File an Plan Appeal?
9. How do I Contact my Plan to file an Appeal?
10. For Some Actions You May Request to Continue Service During the Appeal Process
11. How Long Will it Take CPHL to Decide My Plan Appeal?
12. Expedited Appeal Process
13. If the Plan Denies My Appeal, What Can I Do?
14. State Fair Hearings
15. State External Appeals
16. Contacting the New York State Department of Health

• What are Complaints and Appeals?                              

  Complaint: A complaint is any communication by you to us of dissatisfaction about the care and/or treatment you receive from our staff or providers of covered services. For example, if someone was rude to you or you do not like the quality of care or services you have received from CPHL, you can file a complaint.

  Appeal: A disagreement with a decision made by CPHL regarding your services. You can ask us to review that decision by filing an appeal and we will decide if the action taken was appropriate.Some examples of actions that may be appealed include, but not limited to:

  • denied or limited services requested by you or your provider
  • decided that a requested service is not a covered benefit
  • reduced, suspended or terminated services that we already authorized
  • denied payment for services

You will have sixty (60) calendar days from the date on the notice sent to you regarding the action taken by CPHL to file an appeal. If you want services to continue while the appeal is being reviewed, you must request the appeal as “aid continuing” within 10 days of the date we sent you the notice or the effective date of the action. The appeal may be made verbally or in writing.

An appeal will be decided as quickly as possible, but no later than 30 calendar days from your appeal request. When a delay would significantly increase the risk to your health, your appeal will be expedited and a decision will be made within 2 business days of receiving all necessary information but no more than 3 business days from your appeal request. We may request up to 14 additional days to review your appeal if we need more information and the delay is in your interest. We will notify you in advance if we require more time.

CPHL will send you a letter within 15 business days to acknowledge we received your appeal, unless the appeal is resolved in less than 15 business days. When the appeal is resolved, CPHL will send you a resolution letter within the time frames discussed above, describing how your appeal was resolved.

How Can I File A Complaint And/or Appeal

As a member of our plan, you may file a complaint and/or appeal or you may appoint someone on your behalf to file for you by

• Contacting our Member Services at 1-855-270-1600 Ext. 3792 (or TTY 711) 7 days a week, 8AM-8PM
• You can also email us at: GandA@centersplan.com
• You may send us a fax at: 347-505-7089
• Mail to:

Centers Plan for Healthy Living 
75 Vanderbilt Avenue
Staten Island, NY 10304
Attention: Grievance and Appeals Department

When submitting a complaint or an appeal in writing, please make sure to provide your name, phone number, and the nature of your complaint. Make sure to sign and date your written complaint.

More information regarding CPHL’s complaint process can be found in the Member Handbook.

If you are still unsatisfied with the decisions made by CPHL, you have the right to contact the New York State Department of Health at 1-866-712-7197.

• The Complaint Process                      

  You may file a complaint to us orally or in writing. The person who receives your complaint will record it, and appropriate plan staff will oversee the review of the complaint. Within 15 business days, we will send you a letter informing you that we received your complaint, and a description of our review process.  We will review your complaint and give you a written answer within one of two timeframes:

  • If a delay in our response would be a risk to your health, we will respond within 48 hours after receipt of necessary information but no more than 7 days from receipt of the complaint.
  • For all other types of complaints, we will notify you of our decision within 45 calendar days of receipt of all necessary information, but no more than 60 calendar days from the receipt of the complaint.

  The review period of a complaint can be extended for up to 14 additional calendar days if you request it, or if we need more information and the delay is in your interest.

  Our answer will describe what we found when we reviewed your complaint and our decision about your complaint 

• How do I Appeal a Complaint Decision?

  If you are not satisfied with the decision we make concerning your complaint, you may request a second review of your issue by filing a complaint appeal.  You must file a complaint appeal in writing. It must be filed within 60 business days of receipt of our initial decision about your complaint. Once we receive your appeal, we will send you a written acknowledgement telling you the name, address and telephone number of the individual we have designated to respond to your appeal. All complaint appeals will be conducted by appropriate professionals, including health care professionals for complaints involving clinical matters, who were not involved in the initial decision.  For standard appeals, we will make the appeal decision within 30 business days after we receive all necessary information to make our decision. If a delay in making our decision would significantly increase the risk to your health, we will use the expedited complaint appeal process. For expedited complaint appeals, we will make our appeal decision within 2 business days of receipt of necessary information. For both standard and expedited complaint appeals, we will provide you with written notice of our decision. The notice will include the detailed reasons for our decision and, in cases involving clinical matters, the clinical rationale for our decision.

• What is an Action?                                              

  When CPHL denies or limits services requested by you or your provider; denies a request for a referral; decides that a requested service is not a covered benefit; reduces, suspends or terminates services that we already authorized; denies payment for services; doesn’t provide timely services; or doesn’t make complaint or appeal determinations within the required timeframes, those are considered plan “actions”. An action is subject to appeal. (See “How do I File an Appeal of an Action?” below, for more information).

• Timing of Initial Adverse Determination (IAD)

  If we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we will send you a notice when we make our decision. If we are proposing to reduce, suspend or terminate a service that is authorized, our letter will be sent at least 10 days before we intend to change the service.

• Contents of the Initial Adverse Determination (IAD) Any notice we send to you about an action will:
  • Explain the action we have taken or intend to take;
  • Cite the reasons for the action, including the clinical rationale, if any;
  • Describe your right to file an appeal with us (including whether you may also have a right to the State’s external appeal and Fair Hearing process);
  • Describe how to file an internal appeal and the circumstances under which you can request that we speed up (expedite) our review of your internal appeal;
  • Describe the availability of the clinical review criteria relied upon in making the decision, if the action involved issues of medical necessity or whether the treatment or service in question was experimental or investigational;
  • Describe the information, if any, which must be provided by you and/or your provider in order for us to render a decision on appeal.

  If we are reducing, suspending or terminating an authorized service, the notice will also tell you about your right to have services continue while we decide on your appeal; how to request that services be continued; and the circumstances under which you might have to pay for services if they are continued while we were reviewing your appeal.

• How do I File an Plan Appeal?                        

  If you do not agree with an action that we have taken, you may appeal. When you file an appeal, it means that we must look again at the reason for our action to decide if we were correct. You can file an appeal of an action with the plan orally or in writing. When the plan sends you a letter about an action it is taking (like denying or limiting services, or not paying for services), you must file your appeal request within 60 calendar days of the date on our letter notifying you of the action.

• How do I Contact my Plan to file an Appeal? To file an appeal you can write to us at:
  Centers Plan for Healthy Living
  Attention: Grievances and Appeals Department
  75 Vanderbilt Ave.
  Staten Island, NY 10304

Or call us at 1-855-270-1600 Ext. 3792

For TTY/TDD Users call 711.  You can also email us at: GandA@Centersplan.com
You may send us a fax at: 1-347-505-7089The person who receives your appeal will record it, and appropriate staff will oversee the review of the appeal.

Within 15 business days we will send you a letter informing you that we received your appeal, along with a description of our review process. Your appeal will be reviewed by knowledgeable clinical staff who were not involved in the plan’s initial decision or action that you are appealing.

• For Some Actions You May Request to Continue Service During the Appeal Process 

  If you are appealing a reduction, suspension or termination of services you are currently authorized to receive, you may request to continue to receive these services while we are deciding your appeal. We must continue your service if you make your request to us no later than 10 days from our mailing of the notice to you about our intent to reduce, suspend or terminate your services, or by the intended effective date of our action, and the original period covered by the service authorization has not expired. Your services will continue until you withdraw the appeal, the original authorization period for your services has been met or until 10 days after we mail your notice about our appeal decision, if our decision is not in your favor, unless you have requested a New York State Medicaid Fair Hearing with continuation of services. (See Fair Hearing Section below).Although you may request a continuation of services while your appeal is under review, if your appeal is not decided in your favor, we may require you to pay for these services if they were provided only because you asked to continue to receive them while your appeal was being reviewed.

• How Long Will it Take CPHL to Decide My Plan Appeal?
  

  Unless you ask for an expedited review, we will review your appeal of the action taken by us as a standard appeal and send you a written decision as quickly as your health condition requires, but no later than 30 days from the day we receive an appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.) During our review you will have a chance to present your case in person and in writing. You will also have the chance to look at any of your records that are part of the appeal review.  We will send you a notice that will identify the decision we made and the date we reached that decision.  If we reverse our decision to deny or limit requested services, or reduce, suspend or terminate services, and services were not furnished while your appeal was pending, we will provide you with the disputed services as quickly as your health condition requires.  In some cases you may request an “expedited” appeal. (See Expedited Appeal Process Section below)

• Expedited Appeal Process                                                                                           

  If you or your provider feel that taking the time for a standard appeal could result in a serious problem to your health or life, you or your designee may ask for an expedited review of your appeal of the action. We will respond to you with our decision within 2 business days after we receive all necessary information. In no event will the time for issuing our decision be more than72 hours after we receive your appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.)If we do not agree with your request to expedite your appeal, we will make our best efforts to contact you in person to let you know that we have denied your request for an expedited appeal and will handle it as a standard appeal. Also, we will send you written notice of our decision to deny your request for an expedited appeal within two (2) business days of the decision.

• If the Plan Denies My Appeal, What Can I Do?                                                           

  If our decision about your appeal is not totally in your favor, the notice you receive will explain your right to request a Medicaid Fair Hearing from New York State, how to obtain a Fair Hearing, who can appear at the Fair Hearing on your behalf, and for some appeals, your right to request to receive services while the Hearing is pending and how to make the request. If we deny your appeal because of issues of medical necessity or because the service in question was experimental or investigational, the notice will also explain how to ask New York State for an “external appeal” of our decision. (See “State External Appeals” in the section below).

• State Fair Hearings

  If we did not decide the appeal totally in your favor, you may request a Medicaid Fair Hearing from New York State within 120 days of the date we sent you the notice about our decision on your appeal.  If your appeal involved the reduction, suspension or termination of authorized services you are currently receiving, and you have requested a Fair Hearing, you may also request to continue to receive these services while you are waiting for the Fair Hearing decision. You must check the box on the form you submit to request a Fair Hearing to indicate that you want the services at issue to continue. Your request to continue the services must be made within 10 days of the date the appeal decision was sent by us or by the intended effective date of our action to reduce, suspend or terminate your services, whichever occurs later. Your benefits will continue until you withdraw the appeal; the original authorization period for your services ends; or the State Fair Hearing Officer issues a hearing decision that is not in your favor, whichever occurs first.  If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the disputed services promptly, and as soon as your health condition requires. If you received the disputed services while your appeal was pending, we will be responsible for payment for the covered services ordered by the Fair Hearing Officer. Although you may request to continue services while you are waiting for your Fair Hearing decision, if your Fair Hearing is not decided in your favor, you may be responsible for paying for the services that were the subject of the Fair Hearing.

• State External Appeals 

  If we deny your appeal because we determine the service is not medically necessary or is experimental or investigational, you may ask for an external appeal from New York State. The external appeal is decided by reviewers who do not work for CPHL or New York State. These reviewers are qualified people approved by York State. You do not have to pay for an external appeal.  When we make a decision to deny an appeal for lack of medical necessity or on the basis that the service is experimental or investigational, we will provide you with information about how to file an external appeal, including a form on which to file the external appeal along with our decision to deny an appeal. If you want an external appeal, you must file the form with the New York State Department of Financial Services within 4 months from the date we denied your appeal.  Your external appeal will be decided within 30 days from the date when your appeal is received. More time (up to 5 business days) may be needed if the external appeal reviewer asks for more information. The reviewer will tell you and us of the final decision within two business days after the decision is made.  You can get a faster decision if your doctor can say that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal within 72 hours. The reviewer will tell you and us the decision right away by phone or fax. Later, a letter will be sent that tells you the decision.You may ask for both a Fair Hearing and an external appeal. If you ask for a Fair Hearing and an external appeal, the decision of the Fair Hearing officer will be the one that counts.

• Contacting the New York State Department of Health                                          

  Remember, if at any time you are dissatisfied with how CPHL has treated you, or how we have handled your complaint, you can contact the New York State Department of Health by writing to:New York State Department of Health
  Bureau of Managed Long Term Care
  One Commerce Plaza
  Room # 1621
  Albany, New York 12210
  Phone: 1-866-712-7197