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AgeWell New York Advantage Plus
Appeals and Grievances

To view the formal Appeals and Grievance Processes, please review Chapter 9 of the Evidence of Coverage and the Member Handbook as applicable:

Grievances (Complaints)

A grievance is any complaint other than one that involves a coverage determination. A grievance can be about administrative issues, such as AgeWell New York staff or doctors’ attitudes and/or their interactions with you. Grievances may include complaints about the timeliness, appropriateness, access to and/or setting of a provided health service, procedure or item.

For example, dissatisfaction with wait times when filling a prescription or the cleanliness or condition of a network facility or provider office. You as a member or your representative must file a grievance after the event or incident that caused the grievance. If a request to have a fast service authorization” or a “fast appeal,” and it is denied, you can file an expedited “fast” grievance.

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

  • We answer most complaints in 30 calendar days.
  • If you have a “fast” complaint, it means we will give you an answer within 24 hours.
  • If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you in writing.

 You can write to us at:

AgeWell New York
Attn: Appeals & Grievances Department 
1991 Marcus Avenue, Suite M107 | Lake Success, New York 11042

Or fax to 1-855-895-0778.

Grievances can be submitted either orally or in writing. You are able to communicate with us by calling at 1-866-237-3210 TTY/TDD 1-800-662-1220.

How do I Appeal a Complaint Decision?

If you disagree with a decision we made about your complaint about your Medicaid benefits, you or someone you trust can file a complaint appeal with the plan.  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.

We will let you know our decision within 30 business days from the time we have all information needed. If a delay would risk your health, you will get our decision in 2 business days of when we have all the information we need to decide the complaint appeal. We will give you the reasons for our decision and our clinical rationale, if it applies.

If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at 1-866-712-7197.

Appeal

An appeal is a complaint you make when you want us to change a decision we made about your care. An appeal is a request from you, member designee or non-contracted provider to reverse or modify an initial determination to deny, reduce or discontinue services or the denial of payment for medical care. The time frame for filing an appeal is 60 calendar days from the date of the notice of the adverse determination. You can file one when we:

  • Deny or limit a service request.
  • Reduce or stop services you have been getting.
  • Refuse to pay for services that you think should be covered.
  • Fail to give services in the required timeframe.
  • Fail to decide an appeal in the required timeframe.

You will get a letter from us when any of these actions occur. This is called the “Integrated Coverage Determination”.  You can file an appeal if you think that the action was made in error.

If you are appealing a decision we made about coverage for care you have not gotten yet, you and/or your provider will need to decide if you need a “fast appeal.”

  • You or your provider can ask for a fast track review if you or your provider believe that a delay will cause serious harm to your health.
  • If your provider tells us that your health requires a “fast appeal,” we will give you a fast appeal.
  • If your case was a concurrent review where we were reviewing a service you are already getting, you will automatically get a fast appeal.

You can write to us at:

AgeWell New York
Attn: Appeals & Grievances Department 
1991 Marcus Avenue, Suite M107 | Lake Success, New York 11042

Or fax to 1-855-895-0778.

Appeals can be submitted either orally or in writing. You are able to communicate with us by calling at 1-866-237-3210 TTY/TDD 1-800-662-1220.

If your expedited appeal request was filed verbally, written notice is not needed. For expedited appeals, we will call you with the decision. We will send a letter with the appeal decision.

If you ask for an expedited appeal and we decide that one is not needed, we will:

  • Transfer the appeal to the timeframe for standard resolution.
  • Make reasonable efforts to try to call you.
  • Follow up within two days of written notice.
  • Inform you verbally and in writing that you may file a grievance about the denial of the expedited process.

AgeWell New York must make its determination as quickly as the member’s health condition requires, but no later than 30 calendar days from the date we receive the request for a standard appeal. The time frame will be extended by up to 14 calendar days by AgeWell New York if the member requests the extension, or also may be extended by up to 14 calendar days if AgeWell New York justifies a need for additional information and documents how the delay is in the best interest of the member.

When AgeWell New York extends the time frame, we will notify the member in writing of the reasons for the delay

In some cases you may be able to continue receiving the services while you wait for your appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for this:

  • Within ten days from being told that your request is denied or care is changing; or
  • By the date the change in services is scheduled to occur.

If your appeal results in another denial, you may have to pay for the cost of any continued benefits that you received.

If our answer is yes to part or all of what you asked for, we must authorize or provide the coverage we have agreed to provide within 72 hours after we get your appeal.

If our answer is no to part or all of what you asked for, we will automatically send your appeal to an independent review organization for a Level 2 Appeal.

Part D Appeal (Redetermination Request)

Redetermination Request Formopens PDF file

Coverage Determination Request Formopens PDF file

If your request for a Part D coverage determination was denied, you or your provider has the right to appeal our decision within 60 calendar days from the date of the notice of the denial.  Once we received your request, we must make a decision no later than 72 hours (for expedited requests) or 7 calendar days (for standard requests) from receipt of the request

You may initiate a Part D Appeal: