How to File an Appeal With MVP Health Care
Learn how to file an appeal with MVP Health Care. Understand your rights, when to appeal, how to submit an appeal, and what to expect after you file.
What is an Appeal?
If MVP says “no” to a service, medication, benefit, or claim, you have the right to ask us to take another look. This is called an appeal.
An appeal is a formal request for MVP to review a decision you disagree with and reconsider it based on the full details of your situation.
Appeals exist to ensure that every member receives a fair, thorough review. They also give you an opportunity to share additional information that may not have been part of the original decision.
When to File an Appeal
You may file an appeal when you believe MVP made an incorrect or incomplete decision about your care or coverage. This includes situations like:
- Denials or limitations of coverage for a service or treatment
- Refusals to pay for a prescription drug
- Determinations that a service or treatment is not medically necessary
- Denials of payment for a claim you believe should be covered
Many members file appeals after receiving a denial notice or an Explanation of Benefits (EOB) showing that a claim was not paid. Others appeal decisions that affect ongoing care, medications, or services recommended by their provider.
How to File an Appeal
You can file an appeal in writing, over the phone, or in person. You may use whichever method is most convenient for you. Some members prefer to call and explain their situation, while others choose to submit a letter and related documents in writing.
To file in writing
Send a letter and any related documents to the MVP Health Care Appeal team at the address below:
MVP Health CareAppeals Department
625 State Street
Schenectady, NY 12305
To file over the phone
Call the Member Services/Customer Care Center at the phone number on the back of your MVP Member ID card.
To file in person
Walk-ins are available during normal business hours at the following locations:
Schenectady625 State Street
Schenectady, NY 12305
Rochester
20 S Clinton Ave
Rochester, NY 14604
To share files by fax
While you can’t file an appeal by fax, you or your health care provider can send supporting materials. When sending materials by fax, it’s best to include your full name and contact information.
Medicare Members or their providers can send supporting materials by fax to 1‑800‑398‑2560.
All other MVP members can send materials to 518‑386‑7600.
Getting Help from an Authorized Representative
If you’d like, you may appoint someone to help you with the appeals process. This is called an authorized representative.
Your authorized representative can be a family member, trusted friend, health care provider, or other advocate. They can help you gather information, communicate with MVP, and submit appeals on your behalf.
What Happens After You File an Appeal?
Once we receive your appeal, we will review all available information. This will include the information you submit as well as other documents like medical records, provider notes, and any further details related to the situation.
When a decision is made, you will receive a written notice. The notice will explain the outcome of your appeal. If additional steps are available, those options will also be clearly explained.
Help and More Information
For complete details about your appeal rights, timelines, and what to expect, review your plan documents.
Most members with Individual and Family Plans, Medicare, Medicaid, Child Health Plus (CHPlus), HARP and Essential Plans can find plan documents in their Member Guide in Gia®.
If you use Gia on your computer, sign into Gia, then select My Plan, then My Benefits. In the Gia by MVP mobile app, tap Benefits and Coverage.
Finding documents for other plans
Other members can request a copy of their plan documents by calling the Member Services/Customer Care Center at the phone number on the back of their MVP Member ID card.