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Types of Complaints

This guide contains information about the number of complaints and appeals filed against New York health insurers. The table summarizes the types of complaints and appeals reported in this Guide.

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Types of Data Complaints Prompt Pay Complaints Internal Appeals External Appeals Grievances Definition Complaints to the State of New York about health insurers', including prompt-pay complaints. Complaints about the timely processing of a claim. A request to a health insurer to reconsider its decision to deny coverage of a medical service that it considers experimental, investigational, not medically necessary or for HMO members, an out-of-network service.* An independent, third-party review of a health insurer's denial of a service considered experimental, investigational, not medically necessary or for HMO members, out-of-network service. A complaint to an HMO about denial of coverage based on limitations or exclusions in the contract. Filed by Consumers, their designee or provider. Consumers, their designee or provider. Consumers or their authorized representative, which may be the provider. The provider may file on their own behalf for services already provided. Consumers or their authorized representative, which may be the provider. The provider may file on their own behalf for services already provided. Consumer or their designee. Reviewed by NYSID or DOH. NYSID. The health insurer's medical director. State-certified, independent external review organization. Internal HMO committee. More information Complaints Prompt Pay Complaints Internal Appeals External Appeals Grievances

*If you are an HMO member, you may appeal when the HMO denies a request for out-of-network service if the HMO offers an alternate service in network.