Complaints and appeals

You can have someone else file a complaint or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:

• Your provider
• Your family member 
• Your friend
• Your legal guardian
• Your attorney
• Another person
   

You have to give written permission to the person, allowing them to act for you. For both complaints and appeals, you can write a letter.
 

If you write a letter, tell us that you want someone else to act for you to file a complaint or appeal. Be sure to include:
 

• Your name

• Your member ID number from your ID card

• The name of the person you want to represent you

• What your complaint or appeal is about

Then, sign the letter and send it to:
 

Aetna Better Health of New York 

Grievance & Appeals Department  

PO Box 81139

5801 Postal Service Road 

Cleveland, OH 44181 

Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.

When we get the letter, the person you chose can act for you. If someone else files a complaint or appeal for you, you can’t file one yourself about the same item. 

Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, those services will continue automatically during your appeal, as long as:

• You file your appeal on or before the last day of the original authorized period, or within 10 days of our decision letter, whichever is later
• The appeal involves stopping, holding or reducing a treatment that was approved before
• The authorization hasn’t expired

Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has been met.
• 10 days have passed since we mailed you our appeal decision.
  

The appeal decision

• If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
• If the appeal decision is in your favor: We’ll provide the disputed services right away if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.

You can speed up your appeal if waiting up to 30 calendar days is harmful to your health. This is a fast-track or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.

You can also ask for a quick decision in situations that involve:
 

• Urgent or emergency care

• A new or continued hospital stay

• Availability of care 

• Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility

If we can’t approve a fast-track appeal, we’ll call to let you know. We’ll also send you a letter. Then, we’ll process your appeal normally, in the usual time frame (30 days). 

If our decision on your internal appeal isn’t in your favor, you can request another appeal. This is an external appeal with reviewers who do not work for us or New York State Medicaid. This group isn’t connected with our plan. And you do not have to pay for an external appeal.

How to ask for an external appeal
 

We’ll send you a letter to explain the outcome of your internal appeal. The letter will include an external appeal application. Just fill out this form completely to ask for an external review. The form will include info about how and/or where to submit the form.

Was the application missing from your letter? If yes, contact us for another copy. Call 1-855-456-9126 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.

Here are some timelines to note:
 

• Within 4 months from the date on your internal appeal decision letter: You or your representative have this much time to file an external appeal. The external reviewers will review your request. Then, they’ll send you a letter. It will explain whether they have accepted your case for review.

• Within 30 calendar days: If the external reviewers accept your case, they’ll make a decision as soon as possible, but won’t take longer than this much time after receiving your request.

• Within 72 hours: The external reviewers will make a decision within this much time if you’ve asked for a quick decision. You can do so if the usual time (30 days) for an external review will harm your health.

You can ask for a state fair hearing from the New York State Office of Temporary and Disability Assistance (OTDA) if you don’t agree with our appeal decision. The state’s rules say you must wait for your internal appeal to be complete first. 

You must also ask for a state fair hearing in writing within 120 days of the date of the appeal decision letter from your internal appeal. 

You have many options to ask for a state fair hearing. Just contact the OTDA:

Online

Complete the online request form. 

By mail

You can mail the paper request form (PDF). Print the form, complete it and mail it to:

NYS Office of Temporary and Disability Assistance Office of Administrative Hearings

Managed Care Hearing Unit

PO Box 22023

Albany, New York 12201-2023

By fax

You can also fax the paper request form (PDF). Print the form, complete it and fax it to 518-473-6735.

By phone

You can call the number that’s right for your situation:
 

• Standard Fair Hearing line: 1-800-342-3334 (TTY: 711)

• Emergency Fair Hearing line: 1-800-205-0110 (TTY: 711)

In person

You can ask for a state fair hearing in person at these locations:

New York City

14 Boerum Place, 1st Floor, Brooklyn, New York 11201

Albany

40 North Pearl Street, 15th Floor, Albany, New York 12243

Visit the Office of Temporary and Disability Assistance website to learn more.

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. If you’re filing a state fair hearing online, by fax, or by mail, check the box on the request form that you want to continue services. 

You must ask for your services to continue in writing within 10 days of the date of our appeal decision letter. Your services will continue until one of these things happens:
 

• You withdraw the appeal.

• The original authorization period for your services has ended.

• The State Fair Hearing Officer denies your request.

If you miss the 10-day deadline, we’ll reduce, hold or stop your services by the effective date.

The state fair hearing decision
 

• If the state fair hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.

• If the state fair hearing decision is in your favor (reverses our decision): We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.