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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.

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 or not medically necessary. An independent, third-party review of a health insurer's denial of a service considered experimental, investigational or not medically necessary. A complaint to an HMO about denial of coverage based on limitations or exclusions in the contract. Filed by Consumers, their designee or providers. Consumers, their designee or providers. Consumers or their authorized representative, which may be the provider. The provider can file on their own behalf for services already provided. Consumers or their authorized representative, which may be the provider. The provider can file on their own behalf for services already provided. Consumers, their designee or providers. Reviewed by NYSID or DOH NYSID The health insurer medical director State-certified, independent external review organization Internal HMO committee More information Complaints Prompt Pay Complaints Internal Appeals External Appeals Grievances