How do I?

Prior authorizations and actions

Certain medications and services may need approval from Senior Whole Health of New York before they’re covered. This is called a prior authorization. Prior authorization is usually required if you need a complex treatment or prescription. Since coverage will not be authorized without it, beginning the prior authorization process early is important. Ask your doctor if a prescription drug or treatment is going to require prior authorization so they can start the process.

For more information about the prior authorization process, please review your Senior Whole Health of New York Member Handbook.

How do I file a complaint or appeal?

We understand there may be times when you aren’t completely happy or satisfied. We try our best to deal with your concerns or issues as quickly as possible and to your satisfaction. You may use either our complaint (grievance) process or our appeal process, depending on what kind of problem you have. 

If you choose to authorize a representative, complete and return the Appointment of Representative Form

  • A complaint 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 complaint with us.  

    You may file a complaint over the phone or in writing.
    To complain by phone, call 1-877-353-0185
    To file a complaint in writing, send a letter to:
                     Senior Whole Health of New York
                     15 MetroTech Center, 11th Floor
                     Brooklyn, NY 11201

    You may also contact the New York State Department of Health anytime for filing complaints by calling them at 1-866-712-7197 or writing to them at:
    Bureau of Managed Long Term Care
    New York State Department of Health
    Corning Tower Room 1911
    Empire State Plaza
    Albany, NY 12237  

    If you do not agree with an action that we have taken, you may 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. 

    To file an appeal by phone, call Senior Whole Health of New York Member Services at 1-877-353-0185 (TTY/TDD: 711). 

    To file an appeal in writing, send a letter to:
    Senior Whole Health of New York
    Attn: Quality Improvement Department
    15 MetroTech Center, 11th Floor
    Brooklyn, New York 11201  

    Fraud, waste and abuse

    Health care fraud, waste and abuse is a serious problem and it affects everyone.

    Fraud is when someone intentionally lies to a health insurance company, Medicaid or Medicare to get a benefit or money. Fraud is intentional with knowledge that the information is false. 

    Waste is when someone overuses health services carelessly. Waste isn’t always intentional. 

    Abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed. 

    Providing medical services that are not needed
    “Up-coding” – charging for a more complex or expensive service than was given
    Billing for services that were not provided
    Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
    Billing for rented medical equipment after it has been returned
    Billing twice for the same service
    Billing for more services than can be performed in one day
    Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a 
    patient to refer other Medicaid members, or to get services that are not needed)

    Using another person’s name to get Medicaid services
    Sharing a member ID card or using another person’s member ID card
    Visiting several doctors to get multiple prescriptions
    Lying to a care coordinator or someone else to try and get a service you don’t need
    Paying a doctor cash for a prescription that is not needed
    Making false documents by changing:
    The date of service
    Medical records
    Referral forms

    Reporting suspected fraud, waste and abuse is easy— and it’s important.

    AlertLine: 1-866-606-3889

    Online reporting:

    Other ways to report suspected fraud:
    Office of Inspector General (OIG)

    To report suspected cases of fraud, waste, or abuse in Federal Health and Human Services (HHS) programs, you may fill out the online OIG Hotline form. You can also call, mail or fax using the information below:

    Office of Inspector General
    U.S. Department of Health & Human Services
    PO Box 23489
    Washington, DC 20026
    Phone: 1-800-HHS-TIPS (8477)
    TTY: 1-800-377-4950
    Fax: 1-800-223-8164
    Centers for Medicare and Medicaid Services 
    1-800-MEDICARE (1-800-633-4227) 

    • You may also send your concerns by mail to:

    Attention: Compliance Officer
     Molina Healthcare of New York, Inc.
     1776 Eastchester Road
     Bronx, NY 10461

    • You can also report to the state:

    To report suspected Medicaid fraud and/or abuse in New York state, call New York State Attorney General's Medicaid Fraud Control Unit toll free 1-800-771-7751 or complete a Medicaid Fraud and Abuse Comment Form, which is available online at:

       or you may also:
       Call the Office of the Medicaid Inspector General (OMIG) Fraud Hotline toll free: 1 (877) 87FRAUD or 1 (877) 873-7283
      or file an allegation online at:
       you may also complete the form and mail it to:
       NYS OMIG Bureau of Fraud Allegations
       800 North Pearl Street
       Albany, NY 12204
       or fax the form to: 1 (518) 408-0480

How do I request a new ID card?

Once you’re enrolled in Senior Whole Health of New York, you’ll get a member ID card. This card has important information for you and your providers.

Always show your member ID card when you go to a health care provider or pharmacy.

If your member ID card is ever damaged, lost or stolen, call Member Services right away at 1-877-353-0185. We will mail you a new card. 

How do I follow and use a care plan?

Once you are enrolled in Senior Whole Health of New York, you will work with your care manager on creating your person-centered care plan. Your care plan will include the types of health services that you need and how you will get them. It will also include your goals and preferences.

Together, we work as a team which includes your care manager, your doctor(s) and most importantly you (and a caregiver or family member, if desired). Your care team will work with you to update your care plan when your healthcare needs change, and at least once per year. 

How do I enroll in Senior Whole Health of New York?

Enroll Now!
Call 1-877-353-0188 (TTY/TDD: 711).

When you call, a Senior Whole Health representative will:
Speak with you, confidentially, about your health care needs
Explain how our plans work and help you determine if it’s a good fit for you
Answer any questions you may have about the plan

Once you’re ready, we’ll put you in contact with New York Medicaid Choice and setup a nurse evaluation and offer a plan of care. If you have not been in a long term care plan for 45 days or longer or you want to join a Medicaid-approved long term care plan for the first time you will also need to have a Conflict-Free Evaluation and Enrollment Center (CFEEC) evaluation. For more information about CFEEC, please visit the New York State Medicaid program’s CFEEC website.

Based on your in-home or virtual visit the assessment nurse will use your comprehensive health assessment to develop a person-centered plan of care based on the assessment of your needs. Once you review and accept your plan of care, you are enrolled in the plan. 

How do I renew?

You need to recertify your Medicaid coverage annually. The Human Resources Administration (HRA) or Local Departments of Social Services (LDSS) will send you recertification instructions. You will also receive a reminder in the mail from us. If you need help completing your recertification, please call Member Services at 1-877-353-0185. 

How do I disenroll in Senior Whole Health of New York?

You can ask to leave SWH of NY at any time for any reason. To request disenrollment, call 1-877-353-0185 (TTY/TDD: 711) or you can write to us.

For more information on disenrolling from SWH of NY or transferring to another MLTC plan, please view the disenrollment section to the Member Handbook.