Complaints, Coverage Decisions, and Appeals for Elderplan Plus Long-Term Care
For members of: Elderplan Plus Long-Term Care (HMO-POS D-SNP)
You have Medicare and Medicaid. Our plan uses one process for most problems with your Medicare and Medicaid benefits. This is called an integrated process. It means you usually start in the same place, no matter which program covers the service.
Which process do I use?
| If you want to… | Use this | Go to |
|---|---|---|
| Ask us to cover medical care, or pay a bill for medical care | Coverage decision | |
| Ask us to cover a Part D drug, or get a drug that is not on our Drug List | Coverage decision or exception | |
| Disagree with a coverage decision we made | Appeal | |
| Tell us you are unhappy with care, service, or waiting times | Complaint | |
| Report fraud, waste, or abuse | This is not a complaint |
Not sure? Call Member Services at 1-877-891-6447 (TTY 711), 8 a.m. to 8 p.m., 7 days a week. The call is free.
Words to know
We use plain words on this page. Your letters and your Evidence of Coverage may use legal words.
| Plain words | Legal words for medical care | Legal words for Part D drugs |
|---|---|---|
| Coverage decision: we decide if we will cover or pay for something | Organization determination | Coverage determination |
| Appeal: you ask us to look again at our decision | Plan reconsideration | Plan redetermination |
| Fast decision or fast appeal | Expedited determination or expedited reconsideration | Expedited coverage determination or expedited redetermination |
| Exception: you ask us to cover a drug in a way we normally would not | Does not apply | Formulary exception or tiering exception |
| Complaint: you tell us you are unhappy with our service or care | Grievance | Grievance |
| Independent review organization: an outside group hired by Medicare that reviews appeals | Independent Review Entity (IRE) | Independent Review Entity (IRE) |
Medical care and long-term care services
Step 1: Ask for a coverage decision
You, your doctor, or your representative can ask us to cover medical care or long-term care services. Call, write, or fax us.
| How to reach us | Coverage decisions for medical care |
|---|---|
| Call | 1-877-891-6447 (TTY 711), 8 a.m. to 8 p.m., 7 days a week. The call is free. |
| Fax | 1-718-759-3643 |
| Write | Elderplan Attn: Member Services 55 Water Street, 46th Floor New York, NY 10041 |
How long it takes:
- Standard decision: usually within 7 calendar days if the item or service needs prior approval (prior authorization). Within 14 calendar days for other items and services. Within 72 hours for Part B drugs.
- Fast decision: usually within 72 hours for medical services. Within 24 hours for Part B drugs.
You can get a fast decision only if waiting for a standard decision could seriously harm your health or hurt your ability to function. If your doctor tells us you need a fast decision, we will give you one.