Grievances and Appeals

How do I express a concern?

To express a concern, all you have to do is speak to a Fallon Health Weinberg-MLTC (FHW-MLTC) Care Team or a staff member.

We will try our best to address your concerns or issues as quickly as possible and to your satisfaction. You may use either our Grievance process or our Appeal process, depending on the concern you have.

There will be no change in your services or the way you are treated by Fallon Health Weinberg-MLTC staff or a health care provider because you file a Grievance or an Appeal. We will maintain your privacy. We will give you any help you may need to file a Grievance or Appeal. This includes providing you with interpreter services or help if you have vision and/or hearing problems. You may choose someone (like a relative or friend or a provider) to act for you. 

To file a Grievance, please call: 

1-866-882-8185 TOLL FREE
(716) 250-3100
TTY users call 711

or write to: 

Fallon Health Weinberg - MLTC
c/o Program Director
461 J.J. Audubon PKWY
Amherst, NY 14228.

When you contact us, you will need to give us your name, address, telephone number and the details of your concern.

What is a Grievance?

A Grievance is any communication by you to us of dissatisfaction about the care and 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 us, you can file a Grievance.

The Grievance process

You may file a Grievance orally or in writing. Each Grievance will be documented, and appropriate FHW-MLTC staff will oversee the review of the Grievance. Within 15 business days of receipt, we will send you a letter telling you that we received your Grievance and a description of our review process. We will review your Grievance and give you a written answer within one of two timeframes. 

  1. If a delay would significantly increase the risk to your health, we will decide within 48 hours after receipt of necessary information
  2. For all other types of Grievances, we will notify you of our decision within 45 days of receipt of necessary information, but the process must be completed within 60 days of the receipt of the Grievance.  The review period can be increased up to 14 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 Grievance and our decision about your Grievance.

How do I appeal a Grievance decision?

If you are not satisfied with the decision we make concerning your Grievance, you may request a second review of your issue by filing a Grievance Appeal. You must file a Grievance Appeal in writing.  It must be filed within 60 business days of receipt of our initial decision about your Grievance. 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 Grievance Appeals will be conducted by appropriate professionals, including health care professionals for Grievances involving clinical matters, who were not involved in the initial decision. 

For standard Grievance 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 Grievance Appeal process. For expedited Grievance Appeals, we will make our Appeal decision within two business days of receipt of necessary information. For both standard and expedited Grievance 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 Fallon Health Weinberg-MLTC 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; restricts, reduces, suspends or terminates services that we already authorized; denies payment for services; doesn’t provide timely services; or doesn’t make Grievance 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 Notice of Action

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 restrict, 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 Notice of Action

The Notice of Action will:

  • Explain the action we have taken or intend to take with the date this action will take place;
  • Cite the reasons for the action, including the clinical rationale, if any;
  • Outline the procedure for you to request an aide to continue when applicable and your responsibilities;
  • Describe your right to file an Appeal (including whether you may also have a right to the State’s external Appeal 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), that must be provided by you and/or your provider in order for us to render a decision on Appeal;
  • Provide information on filing a State Fair Hearing to include:
  • The difference between an Appeal and a Fair Hearing;
  • Information that you do not have to file an Appeal before asking for a Fair Hearing;
  • How to ask for a Fair Hearing

If we are reducing, suspending or terminating an authorized service, and you want your services to continue while your appeal is decided, you must ask for a Fair Hearing within 10 days of the date on the Notice of Action or the intended effective date of the proposed action, whichever is later. 

How do I file an appeal of an Action?

If you do not agree with an Action that we have taken, you may file an 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.  An Action is when the plan sends you a letter regarding an action they are taking such as denying, limiting services, or not paying for services. You have 60 business days from the date the letter was postmarked, or the intended effective date of the proposed action, whichever is later to ask for an Internal Appeal. We will send you a written decision about your appeal within 30 days of your request. When you file an appeal orally we will provide you with a written summary of your request.

How do I contact my plan to file an appeal?

To file an appeal please call:

1-800-333-2535, ext 69950
1-716-250-3100
TTY users call 711

or write to:

Attn: Appeals Department
Fallon Health Weinberg - MLTC
10 Chestnut St.
Worcester MA 01608

The person who receives your appeal will record it, and appropriate staff will oversee the review of the appeal. 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 a continuation of service during the appeal process

If you are appealing a restriction, reduction, suspension or termination of services you are currently authorized to receive, you must request a Fair Hearing to continue to receive these services while your appeal is decided. We must continue your service if you ask for a Fair Hearing no later than 10 days from the date on the Notice of Action about our intent to restrict, reduce, suspend or terminate your services, or by the intended effective date of our action, or the intended effective date of the proposed action, whichever is later.

To find out how to ask for a Fair Hearing and to ask for aid continuing see the Fair Hearing Section below.

Although you may request a continuation of services, if the Fair Hearing 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 case was being reviewed.

How long will it take the plan to decide my appeal of an action?

Unless you ask for your Internal Appeal to be fast tracked (also called an Expedited Appeal), 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 best 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 about the decision we made about your appeal that will identify the decision we made and the date we reached thatdecision. 

If we reverse our decision to deny or limit requested services, or restrict, 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

You or your provider can ask for an Internal Appeal to be expedited if your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life.  Your Internal Appeal will be expedited if your provider says the appeal needs to be faster, you are asking for more of a service then you are getting right now or you are asking for home care services after you leave the hospital. You may ask for an expedited review of your appeal of the action. We will respond to you with our decision within three business days after we receive all necessary information. 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 best 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 a written notice of our decision to deny your request for an expedited Appeal.

If the plan denies my Appeal, what can I do?

If the decision about your Appeal is not in your favor, the notice you receive will explain your right to request a Medicaid Fair Hearing from New York State and 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 your Appeal is denied 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.

Note: You must request a Fair Hearing within 60 calendar days after the date of the Initial Determination Notice. This deadline applies even if you are waiting for us to make a decision on your Internal Appeal.

State Fair Hearings

FHW-MLTC members may also request a Fair Hearing from New York State. The Fair Hearing decision can overrule our decision, whether or not you asked us for an Appeal. You must request a Fair Hearing within 60 calendar days of the date we sent you the notice about our original decision. You can pursue a plan Appeal and a Fair Hearing at the same time, or you can wait until we decide on your Appeal and then ask for a Fair Hearing.  In either case, the same 60 calendar day deadline applies.

If you ask for an Internal or External Appeal, you must still ask for a Fair Hearing on time, or you may lose your chance to have a Fair Hearing. The State Fair Hearing process is the only process that allows your services to continue while you are waiting for your case to be decided. If we send you a notice about restricting, reducing, suspending, or terminating services you are authorized to receive, and you want your services to continue, you must request a Fair Hearing. Filing an Internal or External Appeal will not guarantee that your services will continue. 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.

To make sure that your services continue pending the Appeal, generally you must request the Fair Hearing AND make it clear that you want your services to continue. Some forms may automatically do this for you, but not all of them, so please read the forms carefully. In all cases, you must make your request within 10 days of the date on the notice, or by the intended effective date of our action (whichever is later). 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.

You can file a State Fair Hearing by contacting the Office of Temporary and Disability Assistance:

  • Online Request Form: https://errswebnet.otda.ny.gov/errswebnet/erequestform.aspx

  • Mail a Printable Request Form:
    NYS Office of Temporary and Disability Assistance
    Office of Administrative Hearings
    Managed Care Hearing Unit
    P.O. Box 22023
    Albany, New York 12201-2023

  • Fax a Printable Request Form: (518) 473-6735

  • Request by Telephone:
    Standard Fair Hearing line – 1 (800) 342-3334
    Emergency Fair Hearing line – 1 (800) 205-0110
    TTY line – 711 (request that the operator call 1 (877) 502-6155)

    For more information on how to request a Fair Hearing, please visit:
    http://otda.ny.gov/hearings/request/

Please remember, if your health care is being reduced, stopped or restricted: If you want to keep your health care the same until the Fair Hearing decision, you must ask for a Fair Hearing within 10 days from the date the Initial Adverse Determination notice, or by the date the Action takes effect.

You have a right to a Fair Hearing and an External Appeal and the right to have authorized services continue when requesting a Fair Hearing. 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.

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.

Fallon Health Weinberg-MLTC will not act in any manner so as to restrict your right to a Fair Hearing or influence your decision to pursue a Fair Hearing.

State External Appeals

If we deny your Appeal because the service is:

  • Determined not medically necessary
  • Experimental or investigational
  • Not different from care you can get in our network, or
  • Available from a participating provider who has the training and experience to meet your needs

You may ask for an external appeal from New York State. The External Appeal is decided by reviewers who do not work for Fallon Health Weinberg or New York State. These reviewers are qualified and approved by New York State. You do not have to pay for an external appeal.

Before you ask for an External Appeal, you must file an Internal Appeal and get the Final Adverse Determination notice; or if you ask for an expedited Internal Appeal you may ask for an Expedited External Appeal at the same time or you and Fallon Health Weinberg-MLTC may jointly agree to skip the Internal process and go directly to the External Appeal.

You have four months to ask for an External Appeal from the date you receive the Final Adverse Determination, or from when you agreed to skip the Internal Appeal process.

Your external appeal will be decided within 30 days. The reviewer will inform you and FHW-MLTC of the final decision within two business days after the decision is made.

The External Appeal reviewer will decide an Expedited Appeal in 72 hours or less. The reviewer will tell you and FHW-MLTC the decision right away by phone or fax. A letter will be sent confirming 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 final decision.

Other ways to express a complaint or concern

We hope you will always discuss your concerns with us. However, if you are dissatisfied with Fallon Health Weinberg-MLTC, or if you disagree with the way we have handled your complaint, you also have the right to file a complaint with the New York State Department of Health.

You can call them or write to them at any time at the following location:

New York State Department of Health Division of Long Term Care Services
1-866-712-7197
Bureau of Managed Long Term Care

Take the next step

Contact us

1-716-250-3100
1-866-882-8185 (TTY 711)

8 a.m.–5 p.m., Monday–Friday

Member information

Member Handbook (pdf) ►

Overview of benefits and services ►

Contact us

1-866-882-8185 
8 a.m.–5 p.m., Monday–Friday