Complaints, Coverage Decisions, and Appeals

We use plain words on this page. Your letters and your Evidence of Coverage may use legal words.

Step 1: Ask for a Coverage decision

You, your doctor, or your representative can ask us to cover medical care. Call, write, or fax us.

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.

Step 2: If we say no, you can appeal

An appeal asks us to review our decision again. People who did not make the first decision will review it.

• Deadline: Ask within 65 calendar days from the date on the letter that told you our decision. If you have a good reason for being late, please tell us. We may give you more time.
• Standard appeal: Send your appeal in writing.
• Fast appeal: Write to us or call us.
• How long it takes: Standard appeal, within 30 calendar days (7 calendar days for a Part B drug)—fast appeal: within 72 hours.

If someone other than your doctor appeals for you, send us an Appointment of Representative form (CMS-1696). How to appoint a representative.

Step 3: If we still say no

We will automatically send your appeal to an independent review organization. This is a Level 2 appeal. You do not need to do anything to start it. If you do not agree with that decision, the letter you get will explain the next levels of appeal (Levels 3, 4, and 5).

If you paid a bill you think we should pay

Asking us to pay you back is a type of Coverage decision. Call Member Services at 1-800-353-3765 (TTY 711), or send the bill to:

Elderplan, Inc.
Claims Department
P.O. Box 73111
Newnan, GA 30271

If we say no, you can appeal. For appeals about paying you back, we must answer within 60 calendar days.

To ask us to cover a Part D drug, ask for an exception, or appeal a drug decision, go to our Part D drug page. For help, call Member Services at 1-800-353-3765 (TTY 711).

A complaint (grievance) is for problems that are not about Coverage or payment. For example:

• You are unhappy with the quality of your care.
• Someone was rude to you, or you waited too long on the phone, in a waiting room, or for a prescription.
• A clinic or doctor’s office was not clean.
• You think we are not meeting our deadlines for decisions or appeals.

How to make a complaint

1. Call Member Services at 1-800-353-3765 (TTY 711), 8 a.m. to 8 p.m., 7 days a week. This is usually the first step.
2. Or write to us. If you write, we will answer in writing.

Deadline: Make your complaint within 60 calendar days after the problem happened.

• How long it takes: Most complaints are answered within 30 calendar days. We may take up to 14 more days if we need more information or you ask for more time. We will tell you in writing if we take extra days.
• Fast complaint: If you are complaining because we said no to a fast decision or fast appeal, or because we took extra time, we will answer within 24 hours.

Other places to complain

• Medicare: Send a complaint about your plan to Medicare at www.Medicare.gov/my/medicare-complaint (opens a non-Elderplan website), or call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048.
• Quality of care: You can also complain to Livanta, New York’s Quality Improvement Organization. Call 1-866-815-5440 (TTY 1-866-868-2289), Monday through Friday, 9 a.m. to 5 p.m. Voicemail is open 24 hours. Write to Livanta BFCC-QIO Program, 10820 Guilford Road, Suite 202, Annapolis Junction, MD 20701. Website: www.livantaqio.com (opens a non-Elderplan website).

You have Medicare and Medicaid. Use the Medicare process on this page for Medicare benefits. Use the Medicaid process for Medicaid benefits. If you need help deciding which one to use, call Member Services at 1-800-353-3765 (TTY 711).

Elderplan for Medicaid Beneficiaries does not cover your Medicaid benefits. To appeal a Medicaid claim, contact your New York State Department of Health (Social Services) office:

Independent Consumer Advocacy Network (ICAN): Free help with Medicaid service or billing problems, and with filing a complaint or appeal. Call 1-844-614-8800 (TTY 711), 8 a.m. to 6 p.m., Monday through Friday. Email ican@cssny.org. Website: icannys.org (opens a non-Elderplan website).

Special rules apply if you think:

• You are being asked to leave the hospital too soon, or
• Your home health care, skilled nursing facility care, or outpatient rehabilitation (CORF) services are ending too soon.

Read Chapter 9 of your Evidence of Coverage, or call Member Services. You can also call Livanta at 1-866-815-5440 (TTY 1-866-868-2289).

• Member Services: 1-800-353-3765 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
• Medicare: 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
• Free Medicare counseling (HIICAP, New York’s SHIP): 1-212-602-4180 inside the five boroughs, or 1-800-701-0501 outside the boroughs. TTY 711 or 212-504-4115.
• Medicare Ombudsman: Helps with Medicare complaints and questions.
• Someone to act for you: A family member, friend, doctor, or lawyer can help you. How to appoint a representative.
• Totals: To get the total number of complaints, appeals, and exceptions filed with Elderplan, call Member Services at 1-800-353-3765 (TTY 711).